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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1006 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 2 2 1.033333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.033333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 3 0.355555 $17.2400 $48.4900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 16 16.215079 $349.4400 $21.5500
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.005556 $0.2800 $50.4000
EXIT -EXIT EXIT ASSESSMENT 5 5 3.983333 $199.1700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 9 3.200000 $240.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 13 4.222221 $316.6600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 6 7.261112 $544.5900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 22 21.527776 $1194.7800 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 22.000000 $1221.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 20.000000 $1500.0000 $75.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.822222 $41.9700 $51.0500
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Subtotal (Total Children Is Unduplicated) 55 97 99.592854 $5625.1300 $56.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.422222 $21.1100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 3.672222 $844.6100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 20 12.983333 $649.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.150000 $28.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 76 104 126.069046 $6303.4400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 2.177777 $54.4400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 0.355555 $17.7800 $49.9900
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 4.333334 $216.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.333333 $8.3300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 1.666667 $122.2000 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 11.000000 $275.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 263 306 1354.515876 $67725.8100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 295 438 1565.544440 $15655.4400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 26.004761 $1857.7800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.133333 $64.8200 $57.2000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.211111 $96.2600 $455.9800
SENS -V5264 EARMOLD 1 1 0.211111 $3.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 5.904762 $421.8300 $71.4400
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Subtotal (Total Children Is Unduplicated) 300 907 3120.688883 $109367.2400 $35.0500
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Total 1006 3221.315070 $114992.3700 $35.7000
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Number of Children (Unduplicated) With at Least One Authorization 309