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: 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 1066 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 1 1 3.933333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 4.444444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 13 14 3.727776 $80.3300 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.133333 $6.0000 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.133333 $15.3300 $114.9700
EXIT -EXIT EXIT ASSESSMENT 2 2 2.266667 $113.3400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 6 2.238889 $167.9200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 12 8.744442 $655.8200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 13 10.633333 $797.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 25 21.966666 $1219.1500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 25 25 50.000000 $2775.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 21 22 40.083334 $3006.2600 $75.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.188889 $9.6400 $51.0500
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Subtotal (Total Children Is Unduplicated) 58 122 140.116662 $8846.2700 $63.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 2.661111 $612.0500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 27 29 22.714285 $1135.7200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 3.505556 $87.6400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 75 94 112.411113 $5620.5700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 1.561111 $39.0300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.083333 $4.1700 $49.9800
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 1.500000 $75.0000 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 30.338096 $758.4500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 313 326 1640.253979 $82012.6100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 337 460 1885.976204 $18859.7400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 34.857143 $2490.1900 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.133333 $8.6600 $64.9800
SENS -V5264 EARMOLD 1 1 0.266667 $4.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 6.066667 $433.4100 $71.4400
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Subtotal (Total Children Is Unduplicated) 351 942 3745.328598 $122215.3400 $32.6300
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Total 1066 3889.889704 $131061.6100 $33.6900
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Number of Children (Unduplicated) With at Least One Authorization 352