Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 04-01-18 and 06-30-18 Date of Report: 08-10-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1209 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 3.533334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.533334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 18 6.239682 $134.4700 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.377778 $17.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.377778 $43.4500 $115.0100
EXIT -EXIT EXIT ASSESSMENT 3 3 3.611111 $180.5600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 7 1.233333 $92.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 11 7.027777 $527.0800 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.022222 $1.6700 $74.9300
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 11 1.850000 $138.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 17 8.922222 $495.1800 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 4 5 6.300000 $472.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1776.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 18 18 36.000000 $2700.0000 $75.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.294444 $15.0300 $51.0400
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Subtotal (Total Children Is Unduplicated) 50 110 104.256347 $6594.1700 $63.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 8 9 2.333334 $536.6800 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 21 21 14.350000 $717.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 91 117 124.692855 $6234.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.166667 $4.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 1.133333 $56.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 2.638889 $131.9500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 4.438889 $221.9500 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 5 9.155555 $671.2800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 27.742856 $693.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 341 381 1738.857140 $86942.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 367 534 1945.529355 $19455.3000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 14.780952 $1055.9500 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.377778 $24.5600 $65.0000
SENS -V5264 EARMOLD 1 1 0.755556 $13.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 4.857143 $346.9900 $71.4400
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Subtotal (Total Children Is Unduplicated) 373 1097 3894.810302 $127132.6800 $32.6400
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Total 1209 4002.599983 $133726.8500 $33.4100
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Number of Children (Unduplicated) With at Least One Authorization 374