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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2773 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 3 3 0.577169 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 0.577169 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 37 39 22.715350 $1101.7000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.065753 $1.5600 $23.7200
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 4.857143 $218.5700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 5.218787 $600.1500 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.488889 $24.4500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 35 35 38.087519 $1904.3800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $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 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 10.005479 $555.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 74 75 122.569858 $9192.7600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 41 41 66.041094 $4953.0900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 134 134 202.169852 $11220.4600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 71 71 119.557531 $8966.8300 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.418949 $21.3800 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.252055 $12.8600 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 16 16 5.246349 $267.8300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.827778 $42.2600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 10.321330 $526.9000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 1.358904 $69.3700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 20 20 9.528683 $486.4400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 3 0.627778 $32.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.372222 $19.0000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 20 20 3.233411 $165.0700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 1.372222 $70.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.030137 $1.4700 $48.8800
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Subtotal (Total Children Is Unduplicated) 266 490 635.372552 $41204.3500 $64.8500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 44 48 29.744041 $148721.0000 $5000.0300
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.084932 $6.0800 $71.5800
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.610959 $140.5100 $229.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 40 43 30.009629 $1500.4700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.005518 $0.1400 $24.9200
CONIF -CONIF CONSULT, ITDS FACE TO FACE 210 235 439.194583 $21959.7200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 6.302381 $157.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 81 82 109.176191 $5458.8200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.283333 $7.0800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 23 26.166667 $1308.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.166667 $4.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 156 161 295.285710 $14764.2700 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 3.857143 $282.8000 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 6 559.285714 $13982.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 237 250 1535.404773 $76770.2200 $50.0000
INTR -T1013 INTERPRETER 19 27 56.823875 $2841.2000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 290 444 1720.638583 $17206.3700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 46 250.821433 $17918.6500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 51 51 297.250002 $21235.5300 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.361644 $82.4400 $227.9700
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 4.857143 $2214.8400 $456.0000
SENS -V5264 EARMOLD 3 3 5.648924 $101.6800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 38 218.321430 $15596.8800 $71.4400
TRAV -TRAVS Travel by mile 421 809 137366.921081 $61128.2800 $0.4500
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Subtotal (Total Children Is Unduplicated) 449 2280 142957.222356 $423389.1700 $2.9600
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Total 2773 143593.172077 $464593.5200 $3.2400
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Number of Children (Unduplicated) With at Least One Authorization 460