Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 1881 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 3.221429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 3.221429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 1.672223 $108.9300 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.377778 $17.6800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.377778 $45.1800 $119.6100
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
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 4 4 6.000000 $450.0000 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 8 8 2.722223 $138.9700 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 37 39 12.533335 $639.8400 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 16 16 5.833332 $297.7800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 23 24 5.344442 $272.8200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 70 73 24.905556 $1271.4300 $51.0500
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Subtotal (Total Children Is Unduplicated) 122 178 69.766667 $3836.6500 $54.9900
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.511111 $122.2600 $239.1900
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 7.839682 $391.9900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 106 108 87.593647 $4379.6600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 9.177777 $458.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 267 269 194.552383 $9727.6300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 29 212.587303 $5314.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 344 352 2642.092090 $132104.4900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 362 769 3032.454789 $30324.5200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 33 158.285712 $11307.9400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 6.500000 $371.8000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 33 33 167.428568 $11961.1100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 42.785715 $2445.6300 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $474.2400 $237.1200
SENS -V5264 EARMOLD 1 1 0.377778 $6.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 46 221.342855 $15812.7400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 19.500000 $270.6600 $13.8800
TRAV -TRAVS Travel by mile 22 28 28776.333332 $12805.4700 $0.4500
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Subtotal (Total Children Is Unduplicated) 413 1700 35581.362742 $238280.4800 $6.7000
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Total 1881 35654.350838 $242117.1300 $6.7900
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Number of Children (Unduplicated) With at Least One Authorization 422