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: 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 2541 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 5.857143 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 5.857143 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 29 6.614993 $320.8200 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.189041 $2.3800 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.189041 $4.0700 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.443836 $3.6700 $8.2600
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.443836 $20.6000 $46.4200
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.760470 $124.2200 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.571429 $295.7100 $115.0000
EXIT -EXIT EXIT ASSESSMENT 59 59 125.017809 $6250.8900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 0.016437 $1.2400 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 4.350684 $241.4600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 69 69 53.754782 $4031.6600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 49 49 58.108211 $4358.1500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 94 94 91.752037 $5092.2800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 45 45 48.605473 $3645.4400 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.167123 $8.5300 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 7 7 2.249316 $114.8300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 10 1.260884 $64.3800 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 0.917808 $46.8600 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 12.461840 $636.1700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.088889 $106.6400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.460273 $23.5000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 1.514459 $77.3200 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.683334 $34.8900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 5 1.733486 $88.5000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 28 28 6.978008 $356.2400 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.038356 $1.9200 $50.0600
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Subtotal (Total Children Is Unduplicated) 256 451 429.377334 $26252.7600 $61.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 29 6.443227 $32215.5000 $4999.9000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.221918 $51.0400 $229.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 37 39 15.242526 $762.1000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.344444 $58.6100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 187 213 331.700001 $16585.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 6.050000 $151.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 64 100.233336 $5011.6800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 31.699999 $1585.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.866667 $21.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 140 151 225.300001 $11265.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.866667 $21.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 14 340.000001 $8499.9900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 218 230 1388.485726 $69424.2500 $50.0000
INTR -T1013 INTERPRETER 29 45 66.773765 $3338.6900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 251 371 1398.194013 $13981.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 53 55 365.035716 $26078.1400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 48 48 312.909524 $22354.2500 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.443836 $101.1900 $227.9800
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 2.571429 $1172.5600 $455.9900
SENS -V5264 EARMOLD 2 2 3.015265 $54.2700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 65 424.142857 $30300.7500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 3.428571 $196.1200 $57.2000
TRAV -TRAVS Travel by mile 375 727 112987.981125 $50279.6600 $0.4500
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Subtotal (Total Children Is Unduplicated) 402 2089 118013.950614 $293510.3000 $2.4900
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Total 2541 118449.185091 $319763.0600 $2.7000
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Number of Children (Unduplicated) With at Least One Authorization 414