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: 07-01-16 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 5567 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 7 7 3.000000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 15 16 114.626984 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 23 117.626984 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 6 6.000000 $291.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.933333 $47.9200 $51.3500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.172222 $3.6800 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.744444 $9.3900 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 110 119 201.228569 $4336.4700 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 28.228571 $233.1700 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.955556 $24.1900 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.072222 $5.5700 $77.1100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.994444 $20.5600 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 8 5.738889 $258.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 7 7.327777 $842.6900 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.677778 $133.8900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 21 22 240.665873 $12033.2900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 2.738889 $205.4200 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 58 78.722218 $5904.1400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 85 147 191.893067 $14391.9200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 1.677778 $125.8400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 30 38 61.248413 $4593.6400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 116 199 301.056558 $16708.6000 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 54 54 90.544443 $5025.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 33.011111 $2475.8300 $75.0000
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Subtotal (Total Children Is Unduplicated) 302 698 1256.632155 $67670.6600 $53.8500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 18 12.788888 $63944.0000 $4999.9700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 3.294443 $164.7200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 56 56 32.238397 $1611.9000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 7.632540 $546.5600 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 29 30 36.673021 $8434.9300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 137 172 396.680957 $19834.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 6.188889 $154.7200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 381 660 1610.132189 $80506.6100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 32 43 80.661111 $2016.5300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 12.300000 $615.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 14.066667 $703.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 26 41 213.185716 $15630.7800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 35 47 334.871429 $8371.7800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 863 1543 18116.377785 $905818.9300 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 881 2198 19890.299669 $198903.0000 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 3 1.055555 $68.6100 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 3 2.111111 $481.3300 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 2.027778 $924.6800 $456.0000
SENS -V5264 EARMOLD 5 6 7.505554 $135.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 2.600000 $185.7400 $71.4400
TRAV -TRAVS Travel by mile 1 1 3.642857 $1.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 901 4846 40788.334556 $1309153.9300 $32.1000
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Total 5567 42162.593695 $1376824.5900 $32.6600
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Number of Children (Unduplicated) With at Least One Authorization 911