Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 2007 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 17 18 11.600002 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 18 11.600002 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.112329 $0.9300 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.112329 $2.8400 $25.3000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.900000 $103.5000 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 9 13 2.448931 $122.4600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 9 9 7.186302 $359.3100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 6.010958 $450.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 8.010958 $600.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 4.005479 $222.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 161 161 266.419950 $19981.5300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 118 118 210.345983 $15775.9700 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 69 69 97.106841 $7283.0400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 32 32 52.032874 $2887.8300 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 36 37 10.287694 $525.1900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 4.538888 $231.7100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 14 15 8.428064 $430.2600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 21 21 3.722224 $190.0300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.455556 $23.2600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 2.783333 $142.0900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 10 10 3.621082 $184.8600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 60 63 11.342238 $579.0200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 11 11 4.072222 $207.8900 $51.0500
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Subtotal (Total Children Is Unduplicated) 327 598 706.127492 $50465.1600 $71.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.041096 $15205.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.455556 $22.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.455556 $104.7900 $230.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 13 5.404111 $270.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.499999 $62.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 144 94.545233 $4727.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 112 124 145.261111 $3631.5300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 80 144 75.794440 $3789.7000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 41 72 72.161114 $1804.0400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 72 37.166662 $1858.3100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 46 48.650003 $1216.2600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 95 99 69.750793 $3487.5400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 96 99 116.794442 $2919.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 18.857143 $471.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 166 184 1144.582538 $57229.1200 $50.0000
INTR -T1013 INTERPRETER 1 1 0.122222 $6.1100 $49.9900
OCCT -97530 OT SESSION BY LICENSED OT 81 83 474.678570 $33911.0500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 79 85 512.553569 $29318.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 41 43 287.850001 $20564.0000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 35 39 200.842857 $11480.1800 $57.1600
SENS -V5060 BEHIND EAR HEARING AID
1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 2 2 1.355556 $24.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 115 124 749.926186 $53574.7600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 35.000000 $485.8000 $13.8800
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Subtotal (Total Children Is Unduplicated) 348 1391 4098.748758 $246393.1700 $60.1100
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Total 2007 4816.476252 $296858.3200 $61.6300
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Number of Children (Unduplicated) With at Least One Authorization 485