Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 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 1250 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 3 4 8.266667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 4 8.266667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 1.861111 $23.4700 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 18 18 4.705557 $101.4100 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.127778 $5.7500 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.127778 $14.7000 $115.0200
EXIT -EXIT EXIT ASSESSMENT 3 3 141.000000 $7050.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 5 2.033333 $152.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 14 2.666667 $200.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 8 3.766668 $282.5100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 14 7.666666 $425.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 30.000000 $1665.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 17 34.000000 $2550.0000 $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) 56 108 236.250002 $13032.8600 $55.1700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 4.766667 $23833.5000 $5000.0300
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 1.955556 $449.7900 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 22 14.405556 $720.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 89 121 104.588887 $5229.4400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.205555 $5.1400 $24.9900
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 1.294445 $64.7300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 2.694445 $134.7300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 1.977778 $98.8900 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 7 7.055556 $517.3200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 14 50.174601 $1254.3600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 346 382 1745.634933 $87281.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 369 552 1970.366674 $19703.6500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 16.619048 $1187.2600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.800000 $274.5600 $57.2000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.127778 $8.3100 $65.0100
SENS -V5264 EARMOLD 1 1 0.255556 $4.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 1.428571 $102.0600 $71.4400
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Subtotal (Total Children Is Unduplicated) 381 1138 3929.351606 $140895.3100 $35.8600
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Total 1250 4173.868275 $153928.1700 $36.8800
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Number of Children (Unduplicated) With at Least One Authorization 382