Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4246 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 28 28 94.562701 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 5.714286 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 2.544445 $94.1500 $37.0000
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Subtotal (Total Children Is Unduplicated) 31 34 102.821432 $94.1500 $0.9200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 11 34.799087 $1687.7600 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 2.013492 $30.0600 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 2.013492 $38.6600 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 2.013492 $20.9800 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 2.013492 $44.2000 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 2.013492 $17.6200 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 5 5 2.013492 $16.2300 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 2.013492 $43.9700 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 2.013492 $58.1900 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 2.013492 $131.1600 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 2.013492 $51.4000 $25.5300
EXIT -EXIT EXIT ASSESSMENT 113 116 232.000000 $11600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 16 16 25.008219 $1875.6200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 14.077778 $1055.8400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 12 12 19.500000 $1462.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 17 23.010959 $1277.1000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 163 165 256.083559 $19206.2800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 63 63 108.000000 $8100.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 46 46 75.506850 $5663.0100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 211 211 332.598629 $18459.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 88 106 149.124953 $11184.3500 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 3.285714 $164.2900 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 1.000000 $51.0500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $51.0500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 10 10 160.659818 $8201.6900 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 82.615982 $4217.5500 $51.0500
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Subtotal (Total Children Is Unduplicated) 456 845 1542.406468 $94961.8700 $61.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 34.990456 $174952.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 87.714286 $4385.7200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 172 187 211.808272 $10590.3900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 2.319445 $57.9900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 65 80 214.687497 $10734.3700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 134.321428 $6716.0700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 33 123.494642 $6174.7400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 41 42 97.265872 $4863.3000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 526 548 3738.936511 $186946.7700 $50.0000
INTR -T1013 INTERPRETER 60 68 237.683529 $11884.1700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 698 1023 5359.940763 $53599.3800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 18 149.876320 $10707.1600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 64 68 403.658737 $28837.3300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 12.384128 $707.8800 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 76 91 518.470967 $37039.5600 $71.4400
TRAV -TRAVS Travel by mile 728 1172 13084.318080 $5822.5200 $0.4400
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Subtotal (Total Children Is Unduplicated) 748 3367 24412.870933 $554069.3300 $22.7000
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Total 4246 26058.098833 $649125.3500 $24.9100
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Number of Children (Unduplicated) With at Least One Authorization 810