Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 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 2160 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 29 13.885075 $673.4300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.035616 $0.5300 $14.9200
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.035616 $0.3700 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.035616 $0.3100 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.035616 $0.7800 $21.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.035616 $0.8200 $22.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 3.428571 $160.4600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 3.428571 $410.0600 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 4 4 2.339725 $116.9900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 43 44 25.464231 $1273.2300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 2.020547 $151.5500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 4.015068 $222.8400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 102 102 84.056143 $6304.2800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 12.046573 $903.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 114 115 92.117787 $5112.5900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 30 30.097256 $2257.3100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 1.128996 $57.6400 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 19 4.919791 $251.1500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 7 12.413516 $633.7100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 25 27 4.936986 $252.0200 $51.0500
SCREEN-T1023 SCREENING 7 7 2.077094 $103.8600 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.038356 $1.9600 $51.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 1.317809 $67.2700 $51.0500
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Subtotal (Total Children Is Unduplicated) 240 434 299.915654 $18957.0400 $63.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 29 13.766582 $68833.5000 $5000.0400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 41 43 10.958643 $547.9200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 9.768055 $244.2000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 136 168 295.599130 $14779.9500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 8 14.566665 $364.1600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 31 42.455933 $2122.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 32.499998 $1624.9900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.166667 $29.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 97 172.360321 $8618.0300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.900000 $47.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 15 521.347620 $13033.6800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 170 178 991.076200 $49553.7800 $50.0000
INTR -T1013 INTERPRETER 10 15 25.214807 $1260.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 229 361 1344.125764 $13441.2300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 48 369.919045 $26427.0100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 60 62 400.750295 $28629.6100 $71.4400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 3.428571 $1625.9800 $474.2400
SENS -V5264 EARMOLD 1 1 3.428571 $61.7100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 53 53 349.009002 $24933.2000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.213699 $2.9700 $13.8800
TRAV -TRAVS Travel by mile 327 588 78794.522418 $35063.5700 $0.4500
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Subtotal (Total Children Is Unduplicated) 360 1726 83398.077986 $291245.6900 $3.4900
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Total 2160 83697.993640 $310202.7300 $3.7100
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Number of Children (Unduplicated) With at Least One Authorization 379