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 1622 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
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.055556 $4.2900 $77.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.133333 $44.1200 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.055556 $2.5000 $45.0400
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 5 5 4.400000 $330.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 5 4.400000 $330.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 87 100 99.757839 $5137.1400 $51.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 1.883334 $9417.0000 $5000.1800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.250000 $12.5000 $50.0000
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
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 6 6 27.161905 $1358.1000 $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 2 2 12.142857 $867.4900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 3 9.904762 $707.5900 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.055556 $25.3500 $456.3600
SENS -V5264 EARMOLD 1 1 0.055556 $1.0000 $18.0100
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Subtotal (Total Children Is Unduplicated) 446 1519 3176.990914 $60293.1600 $18.9800
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Total 1622 3277.604309 $65430.3000 $19.9600
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Number of Children (Unduplicated) With at Least One Authorization 449