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: 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 1239 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 1 1 1.000000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 15.676190 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 16.676190 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.366667 $211.7900 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 0.600000 $8.3200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 18 18 6.994445 $165.7700 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.311111 $14.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.311111 $35.7800 $115.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 4.000000 $200.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 15 8.261111 $619.5800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 17 28 16.944445 $1270.8400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 12 8.700001 $652.5100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 22 17.288889 $959.5300 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
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Subtotal (Total Children Is Unduplicated) 50 110 71.777780 $4360.1100 $60.7400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 6.844445 $34222.5000 $5000.0400
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.444444 $31.8200 $71.6000
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 3.972223 $913.6300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 15 16 8.888889 $444.4500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 79 102 128.776986 $6438.8600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.605556 $15.1400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 19 17.383333 $869.1700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 10 8.194444 $409.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 14.766668 $738.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 9 15.211111 $1115.2800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 30.761905 $769.0400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 345 387 1727.730151 $86386.4800 $50.0000
INTR -T1013 INTERPRETER 1 1 1.233333 $61.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 358 527 1878.847620 $18788.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 9.171430 $655.2100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.428571 $424.9200 $57.2000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.311111 $20.2200 $65.0000
SENS -V5264 EARMOLD 1 1 0.622222 $11.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 16.304762 $1164.8100 $71.4400
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Subtotal (Total Children Is Unduplicated) 371 1126 3877.499204 $153480.9100 $39.5800
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Total 1239 3965.953174 $157841.0300 $39.8000
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Number of Children (Unduplicated) With at Least One Authorization 373