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: 07-01-16 and 09-30-16 Date of Report: 10-26-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1508 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 2 2 0.266667 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 9.296032 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 9.562699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.194444 $9.1500 $47.0800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.744444 $7.7600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 11 11 2.927777 $64.2600 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.072222 $4.7000 $65.1200
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.433333 $67.0800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.777777 $212.6100 $119.5900
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.677778 $133.8900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 5 5 6.000000 $300.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 1.883333 $141.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 5 4.650000 $348.7500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 23 33 31.124198 $2334.2900 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.666667 $50.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 17 18 13.105555 $982.9100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 34 47 37.229753 $2066.2300 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 28 28 50.522222 $2803.9800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 14 25.500000 $1912.5000 $75.0000
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Subtotal (Total Children Is Unduplicated) 101 180 181.509503 $11487.8800 $63.2900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 0.983333 $4916.5000 $4999.8300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.516666 $25.8300 $49.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 38 38 15.232843 $761.6300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 6.071429 $434.7700 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 47 51 274.372224 $13718.6200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 145 200 270.037299 $13501.8500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 12 15 17.894445 $447.3600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 13 32.583334 $2389.0100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 14 59.823810 $1495.6000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 322 378 2062.886516 $103144.3100 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 369 596 2430.961916 $24309.6200 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.772222 $50.1900 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 1.544444 $366.2100 $237.1100
SENS -V5264 EARMOLD 3 3 3.322221 $59.8000 $18.0000
TRAV -TRAVS Travel by mile 1 1 3.642857 $1.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 387 1322 5184.645559 $165772.9200 $31.9700
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Total 1508 5375.717761 $177260.7900 $32.9700
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Number of Children (Unduplicated) With at Least One Authorization 393