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: 04-01-17 and 06-30-17 Date of Report: 08-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1293 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 1.466666 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 11.085714 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 12.552380 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.294444 $6.2900 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 29 29 14.233331 $306.7200 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.122222 $5.5000 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.122222 $14.0500 $114.9800
EXIT -EXIT EXIT ASSESSMENT 7 8 9.750000 $487.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 0.383334 $28.7600 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 4 2.316667 $173.7500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 12 23 13.777777 $1033.3300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 6 3.550000 $266.2500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 12 21 10.644444 $798.3300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 25 49 30.538890 $1694.9100 $55.5000
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 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 156.285714 $8673.8600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 3.000000 $225.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 66 158 249.019045 $14014.2500 $56.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.327778 $1639.0000 $5000.3400
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 3.483334 $801.1800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 45 44.858731 $2242.9400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 113 153 155.205848 $7760.2900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 1.887301 $47.1800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.411111 $20.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.300000 $15.0000 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 21.263491 $1559.0400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 14 55.823808 $1395.6000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 348 371 1538.109525 $76905.4800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 376 504 1715.958229 $17159.5800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 2.838096 $202.7500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 7.428572 $424.9100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.571429 $112.2600 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.122222 $7.9400 $64.9900
SENS -V5264 EARMOLD 1 1 0.122222 $2.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 4.266666 $304.8100 $71.4400
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Subtotal (Total Children Is Unduplicated) 393 1128 3555.978363 $110675.7200 $31.1200
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Total 1293 3817.549788 $124689.9700 $32.6600
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Number of Children (Unduplicated) With at Least One Authorization 402