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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2674 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 1.300000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.300000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 34 18.853077 $914.3700 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.299011 $16.3800 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.150000 $3.2300 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.066667 $8.8100 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.066667 $27.0000 $25.3100
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 8.285714 $384.6200 $46.4200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.066667 $22.0600 $20.6800
EXIT -EXIT EXIT ASSESSMENT 52 53 74.383105 $3719.1500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 2.010958 $150.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.010958 $333.6100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 86 86 121.658894 $9124.4600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 52 52 77.158899 $5786.9400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 94 95 134.647933 $7472.9900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 38 38 66.027395 $4952.0600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 0.635160 $32.4300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 9 1.243381 $63.4800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 9 1.778157 $90.7800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.473972 $24.2000 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 6 6 1.143303 $58.3700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.184476 $9.4200 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 1.369177 $69.8900 $51.0400
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.435084 $22.2100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 17 2.542088 $129.7800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 10 10 2.074657 $105.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 259 455 533.576358 $34123.7900 $63.9500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 36 21.100489 $105501.5000 $4999.9600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.066667 $53.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 53 57 38.804850 $1940.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.255556 $31.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 184 225 302.921785 $15146.0800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.833333 $45.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 71 95.216669 $4760.8500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 27.833334 $1391.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 148 202.166664 $10108.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.833333 $45.8300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 9 263.571428 $6589.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 223 250 1318.855562 $65942.7800 $50.0000
INTR -T1013 INTERPRETER 28 42 76.738161 $3836.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 270 431 1496.051328 $14960.5000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 50 269.454761 $19249.8400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 14.000000 $800.8000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 53 54 279.779189 $19987.4300 $71.4400
SENS -V5264 EARMOLD 1 1 0.711111 $12.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 49 49 288.285717 $20595.1000 $71.4400
TRAV -TRAVS Travel by mile 388 767 119121.431387 $53009.0400 $0.4500
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Subtotal (Total Children Is Unduplicated) 417 2218 123822.911324 $344009.4900 $2.7800
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Total 2674 124357.787682 $378133.2800 $3.0400
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Number of Children (Unduplicated) With at Least One Authorization 427