Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4669 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 38 40 44.969842 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.355556 $13.1600 $37.0000
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Subtotal (Total Children Is Unduplicated) 39 41 45.325398 $13.1600 $0.2900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 18 18.047869 $875.3200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $51.3500 $51.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 2.000000 $43.1000 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.000000 $16.5200 $8.2600
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.000000 $41.3600 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.266667 $12.0000 $45.0100
EXIT -EXIT EXIT ASSESSMENT 136 136 272.000000 $13600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 16 16 18.527397 $1389.5600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.066667 $155.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 5.005480 $375.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 11 11.021918 $826.6400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 19.584475 $1086.9400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 208 209 336.255380 $25219.1600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 38 38 59.000000 $4425.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 42 42 67.714286 $5078.5700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 273 274 465.035614 $25809.4800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 91 92 156.002740 $11700.2000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 6.000000 $306.3000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 1.246576 $63.6300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 6.000000 $306.3000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 1.295890 $66.1600 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.533333 $8.0000 $15.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 7 51.123288 $2609.8400 $51.0500
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Subtotal (Total Children Is Unduplicated) 514 888 1504.727580 $94116.9000 $62.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 12.754718 $63773.5000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 9 2.478571 $123.9300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.322222 $23.0700 $71.6000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 188 210 217.238057 $10861.8900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 2.500000 $62.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 64 83 114.195401 $5709.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 47.214286 $1180.3600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 11 11.005556 $550.2800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 38 48.877779 $2443.9000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.500000 $62.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 46 51 63.935713 $3196.7800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.714286 $92.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 574 620 4042.047376 $202102.4000 $50.0000
INTR -T1013 INTERPRETER 108 133 326.928571 $16346.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 737 1083 5499.667918 $54996.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 17 89.155555 $6369.2800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 64 69 338.023016 $24148.3600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 3.968254 $226.8200 $57.1600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.533333 $60.8000 $113.9900
SENS -V5264 EARMOLD 1 1 0.533333 $9.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 79 85 532.785714 $38062.2100 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 7.571429 $433.0800 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 20.366667 $282.6900 $13.8800
TRAV -TRAVS Travel by mile 892 1304 12256.643752 $5454.2100 $0.4500
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Subtotal (Total Children Is Unduplicated) 928 3740 23646.961507 $437033.8800 $18.4800
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Total 4669 25197.014485 $531163.9400 $21.0800
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Number of Children (Unduplicated) With at Least One Authorization 1104