Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-18 and 12-31-18 Date of Report: 02-05-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4903 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 69 71 100.258732 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 69 71 100.258732 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 10 4.966591 $240.8900 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.355555 $8.4300 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.016667 $1.4200 $85.0100
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.422222 $21.5600 $51.0700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.488889 $112.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 157 161 319.500000 $15975.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 3.133334 $235.0100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 10 9.200000 $690.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 6.683334 $370.9300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 88 88 150.505479 $11287.9100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 11.000000 $825.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 3.500000 $262.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 295 295 469.505479 $26057.5600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 297 350 523.500000 $39262.5000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 559 951 1516.777550 $95998.5900 $63.2900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 19.722222 $98611.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 9 5.516667 $275.8400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 3.744444 $861.2100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 177 190 191.131272 $9556.5800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 4 4.000000 $100.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 82 92 167.814288 $8390.7300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 20 39.021429 $1951.0700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.533333 $63.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 39 52.017462 $2600.8800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 57 62 83.107919 $4155.4200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.466667 $61.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 608 655 3833.879374 $191693.9700 $50.0000
INTR -T1013 INTERPRETER 123 129 323.001433 $16150.0900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 779 1138 5176.218668 $51762.1800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 25 145.846826 $10419.3000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 0.571429 $32.6800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 60 62 302.476190 $21608.8900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 15.571429 $890.0600 $57.1600
RSPT -RSPT RESPITE 1 1 3.571429 $0.0000 $0.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 70 390.085715 $27867.7200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 29.638096 $411.3800 $13.8800
TRAV -TRAVS Travel by mile 948 1360 5483.916287 $2440.3400 $0.4500
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Subtotal (Total Children Is Unduplicated) 1003 3881 16275.852579 $449904.3200 $27.6400
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Total 4903 17892.888861 $545902.9100 $30.5100
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Number of Children (Unduplicated) With at Least One Authorization 1196