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 3189 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 36 38 43.603175 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 36 38 43.603175 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 17 17.878006 $867.0800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $51.3500 $51.3500
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 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 3.000000 $225.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 1.500000 $112.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 15.000000 $832.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 8.000000 $600.0000 $75.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.533333 $8.0000 $15.0000
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Subtotal (Total Children Is Unduplicated) 156 177 329.183485 $17019.8500 $51.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 8 2.050000 $102.5000 $50.0000
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 80 107.838258 $5391.9200 $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 37 47.111112 $2355.5600 $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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 34 34 217.228572 $10861.4400 $50.0000
INTR -T1013 INTERPRETER 107 132 324.928571 $16246.4300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 737 1082 5498.467918 $54984.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 6.142857 $438.8500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 17.796825 $1271.4100 $71.4400
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 12 13 76.857142 $5490.6900 $71.4400
TRAV -TRAVS Travel by mile 892 1303 12255.443752 $5453.6700 $0.4500
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Subtotal (Total Children Is Unduplicated) 924 2974 18900.325285 $123581.8400 $6.5400
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Total 3189 19273.111945 $140601.6800 $7.3000
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Number of Children (Unduplicated) With at Least One Authorization 946