Summary Report for FSPSAs Ending During the Report Period Center: 07
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 1083 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 3 3 1.938890 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.938890 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 3.000000 $44.7900 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.000000 $57.6000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.000000 $31.2600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 9 9 3.575342 $78.4800 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 1.471232 $12.8700 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $8.0600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 1.471232 $32.1300 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $57.8000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 2.000000 $130.2800 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $76.7400 $38.3700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 0.471232 $10.7900 $22.9000
EXIT -EXIT EXIT ASSESSMENT 16 16 9.303577 $465.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.068493 $5.1400 $75.0100
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 2.068493 $114.8000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 30 30 40.054790 $3004.1300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 0.161644 $12.1200 $74.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 43 43 32.947944 $1828.6100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 2.649316 $198.7000 $75.0000
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 0.144444 $7.3700 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 3.384398 $172.7600 $51.0500
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Subtotal (Total Children Is Unduplicated) 103 174 116.777616 $6551.0700 $56.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.098630 $493.0000 $4998.4800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 4.800783 $240.0400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 84 94 44.314102 $2215.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.011111 $0.2800 $24.9800
CONIF -CONIF CONSULT, ITDS FACE TO FACE 135 225 533.906799 $26695.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 10 16.285715 $407.1500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 6 7.400001 $370.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.633333 $131.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 6 6.661905 $333.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 6.285714 $157.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 433 489 3142.278289 $157113.8200 $50.0000
INTR -T1013 INTERPRETER 2 2 16.714286 $835.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 0.142857 $1.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 33.142857 $2367.7300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 33.785715 $2413.6400 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 31 201.928573 $14425.7700 $71.4400
TRAV -TRAVS Travel by mile 17 23 146.785715 $65.3200 $0.4400
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Subtotal (Total Children Is Unduplicated) 457 906 4197.176385 $208266.8800 $49.6200
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Total 1083 4315.892891 $214817.9600 $49.7700
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Number of Children (Unduplicated) With at Least One Authorization 527