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: 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 1304 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 1 1 0.511111 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 9.880953 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 10.392064 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.200000 $9.7000 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.166667 $3.5600 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 28 28 22.986511 $495.3600 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.377778 $17.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.377778 $43.4500 $115.0100
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 1.150000 $86.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 16 8.238889 $617.9200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 19 34 10.733333 $805.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 2 0.916667 $68.7500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 17 10.822222 $811.6700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 28 50 30.422225 $1688.4500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 25 25 90.000000 $4995.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 38.000000 $2850.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 84 198 216.392070 $12592.1000 $58.1900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 1.355556 $6778.0000 $5000.1600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 11 11 3.511111 $807.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 34 39.801587 $1990.0900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 3.250000 $81.2500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 97 122 99.884108 $4994.2200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 8.923810 $223.1000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 3.222222 $161.1100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.566667 $78.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.533333 $76.6700 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 8.657144 $634.7500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 33.588889 $839.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 333 365 1571.896040 $78594.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 370 519 1790.278556 $17902.7900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 28.666667 $2047.9500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 10.285714 $588.3400 $57.2000
PHY -97110HM PT SESSION BY PT ASST 1 1 2.800000 $160.0500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.377778 $24.5600 $65.0000
SENS -V5264 EARMOLD 1 1 0.377778 $6.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 1.066667 $76.2100 $71.4400
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Subtotal (Total Children Is Unduplicated) 382 1103 3612.043627 $116116.2600 $32.1500
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Total 1304 3838.827761 $128708.3600 $33.5300
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Number of Children (Unduplicated) With at Least One Authorization 391