Summary Report for FSPSAs Ending During the Report Period Center: 53
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 1398 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 14.722222 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 7 14.722222 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.227778 $10.7300 $47.0900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.172222 $3.3100 $19.2000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 29 29 12.086509 $265.3000 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.433333 $3.7900 $8.7500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.233333 $10.9200 $46.7900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.466667 $55.8200 $119.6100
EXIT -EXIT EXIT ASSESSMENT 5 5 5.238096 $261.9100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 23 11.216668 $841.2600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 17 26 16.583335 $1243.7600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 7 2.544444 $190.8300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 28 50 27.600003 $1531.8200 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 23.450793 $1301.5300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 4.511111 $338.3300 $75.0000
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Subtotal (Total Children Is Unduplicated) 86 166 105.764292 $6107.7900 $57.7500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 4 3.677778 $18389.0000 $5000.0300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.722222 $36.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 13 13 2.638890 $131.9500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 0.538889 $38.5900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 8.440476 $2018.9400 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 28 33 21.666668 $1083.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 3.166667 $79.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 142 179 214.598414 $10729.9300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 12 17 12.027777 $300.6900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 11 19.769047 $1449.4600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 9 16.588889 $414.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 348 385 1890.829377 $94541.3800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 366 552 2076.289696 $20762.8800 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.233333 $15.1600 $64.9900
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.466667 $110.6600 $237.1400
SENS -V5264 EARMOLD 1 1 0.933333 $16.8000 $18.0000
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Subtotal (Total Children Is Unduplicated) 381 1225 4274.588123 $150218.7900 $35.1400
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Total 1398 4395.074637 $156326.5800 $35.5700
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Number of Children (Unduplicated) With at Least One Authorization 386