Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 2033 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 8 8 41.858730 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 42.108730 $9.2500 $0.2200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 16 7.674659 $372.2300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 13 5.205555 $245.1300 $47.0900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 8 10 4.016667 $261.6500 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $22.9000 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 10 10 6.255555 $159.7000 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 5 1.838889 $86.0600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.344444 $41.1900 $119.5800
EXIT -EXIT EXIT ASSESSMENT 17 18 13.082743 $654.1300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.244444 $18.3300 $74.9900
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.422222 $31.6700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.244444 $18.3300 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.477778 $193.0200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 4 0.797260 $59.8000 $75.0000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 3 0.457534 $34.3200 $75.0100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.844444 $43.1100 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 3 1.977778 $30.8500 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.666667 $34.0400 $51.0500
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Subtotal (Total Children Is Unduplicated) 67 91 48.551083 $2306.4400 $47.5100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 35 11.345132 $56727.0000 $5000.1200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.500000 $25.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.500000 $25.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 2.272223 $162.7200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 1.516666 $362.7700 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 28 18.176637 $908.8400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 294 438 367.188885 $18359.4300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 4 1.677778 $41.9500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 3.922222 $196.1100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 3.611111 $180.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 6.688890 $334.4500 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 4.133334 $303.0600 $73.3200
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 7 29.457141 $1472.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 398 457 2522.692880 $126134.5200 $50.0000
INTR -T1013 INTERPRETER 1 1 11.714286 $585.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 415 895 3029.354779 $30293.5200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 3 20.642857 $1474.7300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 12 12 53.828573 $3845.5100 $71.4400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 4 1.677777 $795.6300 $474.2200
SENS -V5264 EARMOLD 3 5 2.877778 $51.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 13 93.014287 $6644.9300 $71.4400
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Subtotal (Total Children Is Unduplicated) 422 1933 6186.793236 $248926.0800 $40.2400
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Total 2033 6277.453049 $251241.7700 $40.0200
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Number of Children (Unduplicated) With at Least One Authorization 430