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: 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 1043 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 12.857143 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 34 34 34.664287 $1282.5800 $37.0000
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Subtotal (Total Children Is Unduplicated) 36 36 48.688097 $1282.5800 $26.3400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 4 4.000000 $194.0000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 2.444443 $33.9000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 9 9 2.522223 $59.7800 $23.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 11.857143 $265.6000 $22.4000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 2 3.000000 $225.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 8 8.166666 $612.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 2 0.783333 $58.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 4 6.383333 $354.2700 $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 2 2 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 36 53 59.157141 $3010.0500 $50.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.000000 $25000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.922222 $46.1100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 4.394444 $1010.7100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 18 18 14.566666 $728.3300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 12 12 18.144444 $907.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 18 25.833333 $1291.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 30 39.973015 $1998.6500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 19 20.377779 $1018.9000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.977778 $24.4500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 12.766666 $936.0500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 13 44.038099 $1100.9500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 235 255 1157.585718 $57879.2400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 339 451 1887.203979 $18872.0300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 41 233.159524 $16656.9300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 16.804761 $961.2300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 37 39 278.738100 $19913.0400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 25.980953 $1485.0700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 27 27 168.199209 $12016.1600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 3.504762 $48.6500 $13.8800
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Subtotal (Total Children Is Unduplicated) 354 954 3959.171452 $161920.3600 $40.9000
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Total 1043 4067.016690 $166212.9900 $40.8700
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Number of Children (Unduplicated) With at Least One Authorization 356