Summary Report for FSPSAs Ending During the Report Period Center: 54
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 2169 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 0.366667 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 0.488889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 0.855556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 19 8.700001 $421.9600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 6.510318 $334.3000 $51.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.822222 $17.7200 $21.5500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 0.916667 $70.7100 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $18.5500 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 3.700000 $76.5200 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.377779 $17.0100 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.055556 $6.3900 $115.0900
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.433333 $21.6700 $50.0000
EXIT -EXIT EXIT ASSESSMENT 59 64 79.524504 $3976.2200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 13 16.500000 $1237.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.088889 $6.6700 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 12 16.800000 $1260.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.600000 $33.3000 $55.5000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.422222 $6.3300 $15.0000
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Subtotal (Total Children Is Unduplicated) 114 143 136.451491 $7504.8300 $55.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 24 20.924278 $104622.0000 $5000.0300
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.250000 $12.5000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 0.094445 $6.7700 $71.6500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.138889 $31.9500 $230.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 59 62 36.859735 $1843.0100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 306 468 309.138819 $15456.9800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 0.977778 $48.8900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 4.227778 $211.3900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 10.138095 $506.9000 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.428571 $104.7500 $73.3200
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 9 53.866667 $2693.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 411 464 2233.964290 $111698.2500 $50.0000
INTR -T1013 INTERPRETER 2 2 1.008219 $50.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 440 944 2709.319853 $27093.2200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 96.360318 $6883.9900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 11 29.704763 $2122.1100 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 0.266667 $121.6200 $456.0600
SENS -V5264 EARMOLD 1 1 0.055556 $1.0000 $18.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 26.619048 $1901.6700 $71.4400
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Subtotal (Total Children Is Unduplicated) 448 2023 5535.343769 $275410.7200 $49.7500
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Total 2169 5672.650816 $282915.5500 $49.8700
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Number of Children (Unduplicated) With at Least One Authorization 450