Summary Report for FSPSAs Initiated During the Report Period Center: 53
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 1441 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 7 7 29.891270 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 29.891270 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 41 41 23.360318 $512.7600 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 11.732540 $102.6600 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.161111 $3.5200 $21.8400
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.577778 $73.8400 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 0.383333 $45.8400 $119.5900
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 6.844444 $342.2200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 10 3.127778 $234.5900 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 13 22 14.541098 $1090.6000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 12 5.405556 $405.4200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 19 34 17.824428 $989.2500 $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) 97 179 162.980606 $8617.1700 $52.8700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 0.805555 $4027.5000 $4999.6600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.400000 $70.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 1.938890 $463.8100 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 47 49 71.011113 $3550.5700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 161 223.612697 $11180.6400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 9 8.899999 $222.5000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 15.888888 $1164.9700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 20.857142 $521.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 361 407 1938.233337 $96911.7600 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 398 593 2222.884922 $22228.8700 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.050000 $3.2500 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.100000 $23.7100 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 1.261111 $598.0600 $474.2400
SENS -V5264 EARMOLD 3 3 0.472222 $8.5000 $18.0000
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Subtotal (Total Children Is Unduplicated) 403 1255 4511.415876 $141125.5600 $31.2800
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Total 1441 4704.287752 $149742.7300 $31.8300
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Number of Children (Unduplicated) With at Least One Authorization 405