Summary Report for FSPSAs Initiated During the Report Period Center: 01
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 4666 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 27 27 34.593653 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.600000 $22.2000 $37.0000
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Subtotal (Total Children Is Unduplicated) 28 28 35.193653 $22.2000 $0.6300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 15 20.436660 $991.1800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.311111 $15.9800 $51.3500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $21.3500 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 2.754490 $59.3600 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.000000 $16.5200 $8.2600
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.000000 $41.3600 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.076712 $3.4500 $44.9900
EXIT -EXIT EXIT ASSESSMENT 136 136 272.000000 $13600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 16 16 18.527397 $1389.5600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.066667 $155.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 5.005480 $375.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 11 11.021918 $826.6400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 19.584475 $1086.9400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 208 209 336.255380 $25219.1600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 38 38 59.000000 $4425.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 42 42 67.714286 $5078.5700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 273 276 481.892756 $26745.0600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 91 92 156.002740 $11700.2000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.084932 $4.3300 $51.0300
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 4.054795 $207.0000 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.030137 $103.6400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.076712 $1.1500 $15.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 7 8.076712 $412.3200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 2.200000 $112.3100 $51.0500
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Subtotal (Total Children Is Unduplicated) 508 888 1480.173360 $92897.7800 $62.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 15 22.365548 $111828.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 17 17 9.850228 $492.5100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 9.714286 $695.6400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.076712 $17.6400 $229.9600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 195 213 223.729305 $11186.4500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 76 89 199.950978 $9997.5600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 15 16.383333 $819.1700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 41 63.355560 $3167.8000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.400000 $35.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 52 84.307937 $4215.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.400000 $35.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 592 613 3938.249260 $196912.3000 $50.0000
INTR -T1013 INTERPRETER 106 136 315.052380 $15752.6300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 758 1078 5511.809018 $55118.0500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 21 136.861904 $9777.4100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.571429 $433.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 58 63 379.684929 $27124.6600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 27.428572 $1567.8100 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 0.311111 $5.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 84 619.785722 $44277.4300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 19.000001 $263.7200 $13.8800
TRAV -TRAVS Travel by mile 802 1300 7320.530089 $3257.6400 $0.4500
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Subtotal (Total Children Is Unduplicated) 831 3750 18909.818302 $497436.5000 $26.3100
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Total 4666 20425.185315 $590356.4800 $28.9000
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Number of Children (Unduplicated) With at Least One Authorization 869