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: 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 1053 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 2 2 3.200000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.033333 $75.2300 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 3 5.233333 $75.2300 $14.3800
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) 4 4 1.577777 $21.8800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 15 4.700000 $111.3900 $23.7000
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.855556 $14.2900 $16.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.200000 $9.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.200000 $23.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 3 3 4.577778 $228.8900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 4 1.988888 $149.1600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 4 1.788888 $134.1600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 8 5.750000 $431.2500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 10 9.233334 $512.4500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.600000 $45.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.600000 $45.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 36 57 38.072221 $2044.4700 $53.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 5 5.000000 $25000.0000 $5000.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.011111 $0.7900 $71.5400
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 5.827778 $1340.3900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 18 14.688889 $734.4500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 44 55 65.227778 $3261.3900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 13.216667 $660.8400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 14.305554 $715.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 17 12.961111 $648.0600 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 7.711111 $565.3800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 8.428572 $210.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 330 354 1897.701608 $94885.0500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 364 470 2002.144469 $20021.4400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 39.743653 $2839.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.571429 $89.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 2.142857 $153.0900 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.200000 $13.0000 $65.0000
SENS -V5264 EARMOLD 1 1 0.400000 $7.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 7.019047 $501.4400 $71.4400
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Subtotal (Total Children Is Unduplicated) 374 993 4098.301634 $151647.6700 $37.0000
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Total 1053 4141.607188 $153767.3700 $37.1300
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Number of Children (Unduplicated) With at Least One Authorization 376