Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2757 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 8 8 6.211111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 6.211111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 30 4.311950 $209.1300 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 0.312329 $6.7300 $21.5500
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.060274 $6.9300 $115.0500
EXIT -EXIT EXIT ASSESSMENT 45 45 24.373972 $1218.7000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 2.021916 $151.6500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.010958 $0.8300 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 101 101 57.668480 $4325.1900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 47 47 47.616430 $3571.2600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 135 135 95.752039 $5314.2800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 53 53 11.736978 $880.3100 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.002740 $0.1400 $49.2700
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 0.169863 $8.6700 $51.0600
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 14 14 5.661568 $289.0200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.323288 $16.5000 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.101370 $5.1700 $51.0200
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 12.733203 $650.0400 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.312329 $15.9500 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.322222 $16.4500 $51.0500
SCREEN-T1023 SCREENING 3 3 0.983333 $49.1700 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.109589 $5.6000 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 17 3.421538 $174.6800 $51.0500
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Subtotal (Total Children Is Unduplicated) 276 494 270.011848 $17027.7900 $63.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 31 5.471843 $27359.0000 $4999.9600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 69 84 16.142687 $807.0900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 1.716666 $42.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 177 224 332.442203 $16622.1000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 15.061904 $376.5500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 48 68.666665 $3433.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 6.266667 $156.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 32 38.925564 $1946.2500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.394444 $59.8600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 130 137 194.698414 $9734.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 3 3.400001 $85.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 24 561.428571 $14035.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 205 226 1248.585713 $62429.2800 $50.0000
INTR -T1013 INTERPRETER 16 20 49.359997 $2467.9900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 273 450 1507.983388 $15079.8100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 59 452.436397 $32322.0900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 66 67 460.471430 $32896.1000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 21.857142 $1249.3600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.060274 $13.7500 $228.1000
SENS -V5264 EARMOLD 1 1 0.060274 $1.0900 $18.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 61 69 435.752446 $31130.1500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 5.714286 $79.3100 $13.8800
TRAV -TRAVS Travel by mile 393 758 97970.214210 $43596.7500 $0.4500
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Subtotal (Total Children Is Unduplicated) 422 2255 103399.111186 $295925.0600 $2.8600
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Total 2757 103675.334145 $312952.8500 $3.0200
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Number of Children (Unduplicated) With at Least One Authorization 441