Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 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 1429 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 1 1 0.555556 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 3 7.142857 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 4 7.698413 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 4 4.000000 $194.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 40 40 28.097617 $605.5000 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.050000 $2.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.100000 $11.5000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 4.955555 $247.7800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 13 39.895237 $2992.1400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 28 53 31.433334 $2357.5100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 17 33 11.133334 $835.0100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 41 75 40.144445 $2228.0200 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 6.285714 $348.8600 $55.5000
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Subtotal (Total Children Is Unduplicated) 84 228 166.095236 $9822.5500 $59.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 0.600000 $3000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.211111 $10.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 15 15 5.300000 $1219.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 31 36 25.944444 $1297.2200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 122 160 144.131752 $7206.6100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 2.250000 $56.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.066667 $3.3400 $50.0200
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.027778 $1.3900 $50.0400
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.433333 $121.6700 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 29.304764 $2148.6400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 44.795238 $1119.8800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 353 400 1800.190474 $90009.5600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 368 550 1920.413494 $19204.1500 $10.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.100000 $22.8000 $228.0000
SENS -V5264 EARMOLD 1 1 0.300000 $5.4000 $18.0000
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Subtotal (Total Children Is Unduplicated) 382 1197 3976.069055 $125426.4400 $31.5500
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Total 1429 4149.862704 $135248.9900 $32.5900
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Number of Children (Unduplicated) With at Least One Authorization 385