Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 1546 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 0.355556 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 22.428572 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 22.784128 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 23 22.787823 $1105.2100 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.455556 $35.1400 $77.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.333333 $48.2500 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.455556 $20.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.455556 $52.3900 $115.0100
EXIT -EXIT EXIT ASSESSMENT 46 51 75.666666 $3783.3300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.711111 $53.3300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 3.466667 $260.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 4.177778 $313.3400 $75.0000
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Subtotal (Total Children Is Unduplicated) 74 85 110.510046 $5671.5000 $51.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 2.177778 $10889.0000 $5000.0500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 0.716667 $35.8400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 68 71 47.052959 $2352.6600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 308 446 395.800549 $19790.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.633333 $40.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 3.388889 $169.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 2.344444 $117.2200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 12 21.200000 $1060.0000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 7 44.866666 $2243.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7 7 40.749206 $2037.4700 $50.0000
INTR -T1013 INTERPRETER 2 2 1.008219 $50.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 456 888 3207.107976 $32071.0900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 31.142858 $2224.8500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 2 9.428572 $673.5700 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.455556 $207.7500 $456.0400
SENS -V5264 EARMOLD 1 1 0.455556 $8.2000 $18.0000
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Subtotal (Total Children Is Unduplicated) 464 1458 3810.529228 $73996.7100 $19.4200
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Total 1546 3943.823402 $79668.2100 $20.2000
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Number of Children (Unduplicated) With at Least One Authorization 473