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 2828 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
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Subtotal (Total Children Is Unduplicated) 28 31 100.276987 $0.0000 $0.0000
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 1 1 1.285714 $19.2000 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.285714 $24.6900 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.285714 $13.4000 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.285714 $28.2200 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.285714 $11.2500 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.285714 $10.3600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.285714 $28.0800 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.285714 $37.1600 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.285714 $83.7500 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.285714 $32.8200 $25.5300
EXIT -EXIT EXIT ASSESSMENT 113 116 232.000000 $11600.0000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.002740 $0.1500 $54.6700
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 13.500000 $1012.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 5.500000 $412.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 14.000000 $777.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 2 3.000000 $225.0000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 3.285714 $164.2900 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.104110 $5.3100 $51.0500
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Subtotal (Total Children Is Unduplicated) 135 161 323.048791 $16473.4300 $50.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.200000 $1000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 87.714286 $4385.7200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 170 185 210.802793 $10540.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.316667 $57.9200 $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 31 32 121.727975 $6086.4100 $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 13 13 86.328571 $4316.4300 $50.0000
INTR -T1013 INTERPRETER 59 67 235.683529 $11784.1700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 693 1015 5312.859810 $53128.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 22.571429 $1612.5000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 47.000000 $3357.6700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 10 54.923810 $3923.7600 $71.4400
TRAV -TRAVS Travel by mile 724 1164 13037.237127 $5801.5700 $0.4400
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Subtotal (Total Children Is Unduplicated) 740 2636 19665.640794 $128308.5400 $6.5200
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Total 2828 20088.966572 $144781.9700 $7.2100
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Number of Children (Unduplicated) With at Least One Authorization 759