Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 2226 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 6.890476 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 6.890476 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 27 4.985539 $241.8000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.186301 $4.0100 $21.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $20.6800 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 10.571429 $475.7100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 10.944032 $1258.5600 $115.0000
EXIT -EXIT EXIT ASSESSMENT 52 52 142.285064 $7114.2600 $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 68 68 53.710946 $4028.3700 $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
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 1.130212 $57.7100 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 1.918797 $97.9500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 1.705675 $87.0800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.927778 $47.3600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.632876 $32.3100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 16 17 11.750945 $599.8900 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.485693 $24.8000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 5 0.622603 $31.7800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 4.423973 $225.8500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 10 10 1.923287 $98.1900 $51.0500
VISD -99202 VISION EVAL DIAG (SIMPLE) 1 1 0.186301 $6.7000 $35.9800
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.147945 $7.4000 $49.9800
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Subtotal (Total Children Is Unduplicated) 224 435 456.555495 $28108.4600 $61.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 29 4.850227 $24250.5000 $4999.8700
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.060274 $13.8700 $230.1000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 41 23.089863 $1154.4700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 160 183 341.366667 $17068.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.733333 $68.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 62 90.233336 $4511.6800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 17 28.349999 $1417.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 109 114 188.899998 $9444.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.733333 $68.3300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 94.285716 $2357.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 186 192 1191.385730 $59569.2800 $50.0000
INTR -T1013 INTERPRETER 28 44 41.826146 $2091.3100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 211 307 1252.168955 $12521.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 46 274.357149 $19600.0600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 15.214285 $870.2600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 39 40 287.841947 $20563.4300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 9.428571 $538.9400 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.060274 $13.7500 $228.1000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 10.757730 $4905.5100 $456.0000
SENS -V5264 EARMOLD 3 3 11.190607 $201.4300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 50 52 358.214288 $25590.8400 $71.4400
TRAV -TRAVS Travel by mile 278 643 103610.371541 $46106.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 301 1789 107841.553302 $252981.5700 $2.3500
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Total 2226 108304.999273 $281090.0400 $2.6000
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Number of Children (Unduplicated) With at Least One Authorization 320