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 3415 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 2 3 3.000000 $145.5000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.744444 $9.3900 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.611111 $13.1700 $21.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.994444 $20.5600 $20.6800
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 -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 24 24 24.283333 $1821.2500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 56 58 46.877776 $3515.8200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.011111 $75.8300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 10 33.292858 $2496.9800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 67 70 82.287301 $4566.9400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.011111 $0.8300 $74.9300
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Subtotal (Total Children Is Unduplicated) 105 194 436.457140 $24833.4500 $56.9000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 6 4.800000 $24000.0000 $5000.0000
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 1 1 6.071429 $434.7700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.944445 $447.2400 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 136 171 396.180957 $19809.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 6.188889 $154.7200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 381 658 1606.065522 $80303.2700 $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 3 3 5.716667 $419.1500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 5 35.652381 $891.3100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 28 33 513.304761 $25665.2500 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 881 2196 19882.533002 $198825.3400 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.311111 $20.2200 $65.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 2.027778 $924.6800 $456.0000
TRAV -TRAVS Travel by mile 1 1 3.642857 $1.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 893 3198 22609.000417 $357108.1000 $15.7900
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Total 3415 23163.084541 $381941.5500 $16.4900
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Number of Children (Unduplicated) With at Least One Authorization 902