Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-18 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 4667 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 46 46 67.917456 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 46 46 67.917456 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 21 14.763395 $716.0300 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.688889 $40.0300 $23.7000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.266667 $10.2600 $38.4700
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 8 8 5.322222 $271.8000 $51.0700
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 -97167 OT EVAL HIGH COMPLEXITY 3 3 5.000000 $255.2500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $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) 560 964 1527.568799 $96463.9700 $63.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 14 21.318341 $106592.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.855556 $42.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 2.894445 $144.7300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 7.714286 $552.4200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 16.225396 $3731.8200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 177 190 185.060333 $9253.0300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 9.233333 $230.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 67 76 157.340478 $7867.0300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 1.600000 $40.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 17 29.677780 $1483.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 37 66.038889 $3301.9500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 48 51 80.434924 $4021.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 3.200000 $80.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 603 625 4422.066729 $221103.3200 $50.0000
INTR -T1013 INTERPRETER 120 131 387.672866 $19383.6500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 790 1061 5760.899670 $57608.9900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 18 145.928570 $10425.1500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 55 57 408.419049 $29177.4600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 21.571428 $1233.0300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 58 433.276196 $30953.2300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 30.571428 $424.3300 $13.8800
TRAV -TRAVS Travel by mile 842 1286 6128.149666 $2727.0300 $0.4500
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Subtotal (Total Children Is Unduplicated) 870 3657 18320.149363 $510378.4300 $27.8600
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Total 4667 19915.635618 $606842.4000 $30.4700
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Number of Children (Unduplicated) With at Least One Authorization 918