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: 01-01-19 and 03-31-19 Date of Report: 05-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1157 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 1.166667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.166667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 3.000000 $145.5000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 2.933336 $40.6900 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 11 11 8.400000 $199.0800 $23.7000
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.511111 $8.5400 $16.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.088889 $4.0000 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.088889 $10.2200 $115.0100
EXIT -EXIT EXIT ASSESSMENT 1 1 0.288889 $14.4500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 10 2.833333 $212.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 19 8.227778 $617.0900 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 12 9.144446 $685.8500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 18 15.050000 $835.2800 $55.5000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 5.500000 $412.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 12.500000 $693.7500 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 51 101 69.566671 $3929.4300 $56.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.133333 $9.5500 $71.5900
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 10.933334 $2514.6800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 16 16 11.322222 $566.1100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 41 49 48.788890 $2439.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 28 25.944445 $1297.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 30 52.771430 $2638.5800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 19 16.500000 $825.0000 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 6.550000 $480.2500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 6 16.752380 $418.8200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 317 342 1445.239665 $72261.9600 $50.0000
INTR -T1013 INTERPRETER 1 1 3.200000 $160.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 355 507 1815.303950 $18153.0400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 21 116.792061 $8343.6300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 14.204761 $812.5100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 6 6 65.833333 $4703.1300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 39.276191 $2805.8900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.933333 $26.8300 $13.8800
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Subtotal (Total Children Is Unduplicated) 357 1055 3697.479328 $138531.6300 $37.4700
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Total 1157 3768.212666 $142461.0600 $37.8100
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Number of Children (Unduplicated) With at Least One Authorization 360