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: 07-01-17 and 09-30-17 Date of Report: 11-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1486 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 3 3.533333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 3 3.533333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 37 37 15.072224 $324.8100 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.472222 $21.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.944444 $108.6100 $114.9900
EXIT -EXIT EXIT ASSESSMENT 5 5 4.594444 $229.7200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 15 27 34.292064 $2571.9100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 22 44 24.033337 $1802.5300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 2 1.450000 $108.7500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 12 21 9.544445 $715.8400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 28 52 28.333335 $1572.5100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 22.000000 $1650.0000 $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 29 30 58.500000 $3246.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 17 34.000000 $2550.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 99 249 235.236515 $15052.6700 $63.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.422222 $2111.0000 $4999.7400
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.144444 $7.2200 $49.9800
AUDE -V5160 DISPENSING FEE BINAURAL 13 13 2.422223 $557.1300 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 37 42 89.878571 $4493.9300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 136 183 188.482643 $9424.1600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 2.550001 $63.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.544444 $27.2200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.300000 $7.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 5.066667 $253.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 10 30.787301 $2257.3200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 26.780951 $669.5200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 326 365 1939.030947 $96951.4800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 370 587 2261.477079 $22614.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 18.495238 $1321.3000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 2.790476 $159.6100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 11.714286 $836.8700 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.944444 $215.3200 $227.9900
SENS -V5264 EARMOLD 1 1 2.833333 $51.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 3.714286 $265.3500 $71.4400
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Subtotal (Total Children Is Unduplicated) 382 1234 4590.379556 $142337.7800 $31.0100
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Total 1486 4829.149404 $157390.4500 $32.5900
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Number of Children (Unduplicated) With at Least One Authorization 384