Summary Report for FSPSAs Ending During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 01-01-19 and 03-31-19 Date of Report: 05-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 695 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 1 1 1.166667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.166667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
EXIT -EXIT EXIT ASSESSMENT 1 1 0.288889 $14.4500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 0.766667 $57.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 2.972223 $222.9200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 5 2.655556 $199.1700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 4.350000 $241.4200 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 19 32 16.033335 $993.4600 $61.9600
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.350000 $80.5000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 11.322222 $566.1100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 41 49 48.788890 $2439.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 28 25.944445 $1297.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 30 52.771430 $2638.5800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 19 16.500000 $825.0000 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 29.733333 $1486.6700 $50.0000
INTR -T1013 INTERPRETER 1 1 3.200000 $160.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 355 507 1815.303950 $18153.0400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 11.142857 $796.0500 $71.4400
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Subtotal (Total Children Is Unduplicated) 356 662 2017.057127 $28540.9300 $14.1500
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Total 695 2034.257129 $29534.4000 $14.5200
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Number of Children (Unduplicated) With at Least One Authorization 357