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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1266 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 2 2 0.500000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 3.792857 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 4.292857 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 2 2.000000 $97.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 42 42 30.176987 $650.3200 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.897619 $15.6700 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.283333 $7.1700 $25.3100
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.961111 $88.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.144445 $246.6200 $115.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 98.833333 $4941.6700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 17 9.127778 $684.5900 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 22 41 29.521003 $2214.0700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.722222 $54.1700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 49 35.898780 $1992.3700 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 4.285714 $237.8600 $55.5000
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Subtotal (Total Children Is Unduplicated) 77 169 216.852325 $11229.7400 $51.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 0.794446 $3973.0000 $5000.9700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.511111 $25.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 2.000000 $100.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 2.983333 $686.1600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 33 39 29.855555 $1492.7800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 108 134 149.026986 $7451.3500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 7 6.150000 $153.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 3.033333 $151.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.966667 $148.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 29.355555 $2152.3500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 9 33.828572 $845.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 323 371 1812.132550 $90606.6600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 334 501 2053.565881 $20535.6600 $10.0000
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 1.255556 $572.5500 $456.0200
SENS -V5264 EARMOLD 2 2 1.244445 $22.4000 $18.0000
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Subtotal (Total Children Is Unduplicated) 341 1093 4128.703990 $128917.9300 $31.2200
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Total 1266 4349.849172 $140147.6700 $32.2200
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Number of Children (Unduplicated) With at Least One Authorization 347