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: 07-01-17 and 06-30-18 Date of Report: 08-10-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5078 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 3 3 1.544444 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 48.385714 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 10 49.930158 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 5 5.755557 $279.1500 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.677778 $14.4700 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 96 102 165.698417 $3570.8100 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 2.372222 $106.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 2.844444 $327.1100 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.005556 $0.2800 $50.4000
EXIT -EXIT EXIT ASSESSMENT 14 14 14.477777 $723.8900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 2.822222 $211.6700 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 37 60 77.525396 $5814.4000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 55 104 89.977782 $6748.3700 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 5 4.511111 $338.3300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 32 51 57.288891 $4296.6800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 76 136 139.755559 $7756.4500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 15 16 29.883334 $2241.2600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 83 84 390.500000 $21672.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 62 65 130.000000 $9750.0000 $75.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.294444 $15.0300 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.011111 $51.6200 $51.0500
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Subtotal (Total Children Is Unduplicated) 274 656 1117.401601 $64069.0000 $57.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 10 8.227778 $41139.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 3.611111 $180.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 39 43 28.466667 $6547.3400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 104 119 181.773015 $9088.6600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 10 10 7.655556 $191.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 311 526 1146.087528 $57304.4400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 15 16 33.395238 $834.8800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 15.394444 $769.7200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 28.055556 $1402.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 2 6.466667 $161.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 16.094445 $804.7300 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 22 25 97.093650 $7118.9000 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 28 29 274.744441 $6868.6100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 877 1450 16101.258725 $805062.8500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 928 2110 17911.782756 $179117.8200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 19 220.690476 $15766.1400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 31.190476 $1784.0900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 11.714286 $836.8700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 6.733333 $384.8800 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 1.900000 $123.5000 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.944444 $215.3200 $227.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.233333 $562.3800 $455.9900
SENS -V5264 EARMOLD 3 4 6.977777 $125.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 8 69.033333 $4931.7500 $71.4400
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Subtotal (Total Children Is Unduplicated) 936 4412 36210.525035 $1141323.8700 $31.5200
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Total 5078 37377.856794 $1205392.8600 $32.2500
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Number of Children (Unduplicated) With at Least One Authorization 946