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 3393 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 1 2 2.000000 $97.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.622222 $34.9600 $21.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.994444 $20.5600 $20.6800
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 1 1 0.127778 $9.5900 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 29 30 27.055555 $2029.1600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 77 80 64.883333 $4866.2500 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 2.194444 $164.5800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 29 29 44.815081 $3361.1500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 90 93 97.487303 $5410.5600 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.000000 $55.5000 $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) 141 268 485.990477 $28240.0900 $58.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 2.055556 $10278.0000 $5000.1100
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 2 3 1.794445 $412.7400 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 137 172 468.964291 $23448.2400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 6.000000 $150.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 369 626 1425.713784 $71285.7000 $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 4 4 9.665080 $708.6500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 6 44.080952 $1102.0300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 29 34 520.223807 $26011.2100 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 976 2201 19568.443927 $195684.4600 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.122222 $7.9400 $64.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 2.027778 $924.6800 $456.0000
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Subtotal (Total Children Is Unduplicated) 980 3103 22141.979141 $333348.9900 $15.0600
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Total 3393 22712.580728 $361589.0800 $15.9200
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Number of Children (Unduplicated) With at Least One Authorization 992