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: 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 5602 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 6 6 3.055555 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 15 16 81.555555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 22 84.611110 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 5 5.000000 $242.5000 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.466666 $9.9600 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 141 153 206.371429 $4447.3000 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 27.284127 $225.3700 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.955556 $24.1900 $25.3100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.994444 $20.5600 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 6 4.983334 $224.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 6.783333 $780.0800 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 22 23 241.799206 $12089.9600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 1.238890 $92.9300 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 65 160.534125 $12040.0500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 88 169 207.163315 $15537.2300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 7 4.561111 $342.0800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 34 56 75.165080 $5637.3900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 113 213 292.771252 $16248.8000 $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 58 59 239.544443 $13294.7200 $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) 309 794 1514.627422 $84133.1900 $55.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 11 8.716667 $43583.5000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.033333 $51.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 8.922221 $446.1100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 42 44 32.450003 $7463.5700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 138 173 469.464291 $23473.2400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 6.000000 $150.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 369 628 1429.780451 $71489.0300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 21 23 46.592856 $1164.8200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 12.711111 $635.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.494444 $74.7200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.766667 $144.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 14.366667 $718.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 25 37 188.999205 $13857.4100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 32 44 377.290475 $9432.2600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 948 1574 17844.785696 $892239.3800 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 976 2202 19573.610594 $195736.1200 $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 2 2 0.405555 $26.3600 $64.9900
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 1.677778 $382.5400 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 2.027778 $924.6800 $456.0000
SENS -V5264 EARMOLD 5 5 7.638888 $137.5000 $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) 990 4786 40051.839443 $1263275.6800 $31.5400
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Total 5602 41651.077975 $1347408.8800 $32.3500
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Number of Children (Unduplicated) With at Least One Authorization 996