Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 2086 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 1 1 1.766667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.766667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 22 2.999773 $145.4900 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.433333 $25.3600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.084932 $1.8600 $21.9400
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.433333 $21.2900 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.433333 $53.1400 $21.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.046575 $1.7900 $38.3900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.433333 $62.1200 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 9.714286 $454.6300 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 9.714286 $1161.8300 $119.6000
EXIT -EXIT EXIT ASSESSMENT 44 44 19.387671 $969.3900 $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 101 101 84.226006 $6317.0300 $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 112 113 82.287650 $4567.0200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 29 20.097256 $1507.3100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 0.679148 $34.6700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 10 10 4.364763 $222.8100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 9 0.969180 $49.4800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 17 17 12.554663 $640.9100 $51.0500
SCREEN-T1023 SCREENING 2 2 0.444444 $22.2200 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.035616 $1.8200 $51.0300
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.123288 $6.2900 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 2.109284 $107.6700 $51.0500
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Subtotal (Total Children Is Unduplicated) 213 397 277.659820 $17652.4300 $63.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 23 3.255329 $16277.0000 $5000.1100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.433333 $121.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 39 44 11.540376 $577.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 4.629166 $115.7300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 158 267.427700 $13371.3800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 7.090476 $177.2600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 33 52.816666 $2640.8300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.666666 $66.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 20 38.866668 $1943.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.200000 $55.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 102 104 183.126982 $9156.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 3 6.733334 $168.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 15 542.142858 $13553.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 171 185 1233.368557 $61668.3800 $50.0000
INTR -T1013 INTERPRETER 9 14 57.964905 $2898.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 204 339 1426.493862 $14264.9200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 39 283.224202 $20233.5200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 57 59 433.857145 $30994.7500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 1.285714 $73.4900 $57.1600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 9.714286 $4606.9100 $474.2400
SENS -V5264 EARMOLD 2 2 11.336508 $204.0600 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 44 45 329.000000 $23503.7400 $71.4400
TRAV -TRAVS Travel by mile 260 590 90768.553274 $40392.0100 $0.4500
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Subtotal (Total Children Is Unduplicated) 293 1688 95679.728007 $257064.1200 $2.6900
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Total 2086 95959.154494 $274716.5500 $2.8600
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Number of Children (Unduplicated) With at Least One Authorization 310