Summary Report for FSPSAs Ending During the Report Period Center: 57
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 2331 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
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 1.538889 $100.2400 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.644444 $30.1600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.644444 $77.0700 $119.5900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 0.027778 $2.0900 $75.0600
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 8.000000 $444.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 6.027778 $452.0900 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 12 12 5.938888 $303.1800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 55 58 21.311110 $1087.9300 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 19 21 17.131745 $874.5700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 47 47 22.377779 $1142.3900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 98 105 38.900004 $1985.8700 $51.0500
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Subtotal (Total Children Is Unduplicated) 197 263 124.542859 $6649.5800 $53.3900
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.311111 $74.4200 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 5 2.033334 $101.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 2.055556 $102.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 111 118 58.009519 $2900.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 29 12.077778 $603.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 302 318 164.946821 $8247.3200 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 46 49 341.285716 $8532.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 378 405 2616.329371 $130816.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 420 925 3041.326987 $30413.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 50 55 234.560316 $16757.0000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 17.785714 $1017.3400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 45 49 271.571429 $19401.0800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 10 52.000001 $2972.3200 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $474.2400 $237.1200
SENS -V5264 EARMOLD 1 1 0.644444 $11.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 60 218.821428 $15632.5900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 23.928571 $332.1300 $13.8800
TRAV -TRAVS Travel by mile 23 31 13918.154761 $6193.5800 $0.4500
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Subtotal (Total Children Is Unduplicated) 489 2068 20977.842857 $244584.2300 $11.6600
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Total 2331 21102.385716 $251233.8100 $11.9100
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Number of Children (Unduplicated) With at Least One Authorization 513