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: 07-01-18 and 06-30-19 Date of Report: 07-21-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4742 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 4 4 5.144444 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 8 67.823810 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 30.744446 $1137.5500 $37.0000
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Subtotal (Total Children Is Unduplicated) 19 21 103.712700 $1137.5500 $10.9700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 14 13.755556 $667.1500 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 26 27 21.138892 $293.2000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 56 61 54.555552 $1292.9600 $23.7000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.366667 $22.8200 $16.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 5 2.966666 $133.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 6 3.977777 $457.4400 $115.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 46.866667 $2343.3400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 26 43 51.811110 $3885.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 41 71 91.268254 $6845.1200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 20 33 42.555553 $3191.6500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 32 56 84.455555 $4687.2800 $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 13 13 22.500000 $1248.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 2.650000 $198.7500 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 161 345 448.368249 $25809.1400 $57.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 23 22.711112 $113556.0000 $5000.0200
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.833333 $91.6700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 3.011112 $215.6300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 27 29 40.838887 $9392.9000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 60 72 47.784921 $2389.2500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 203 293 647.961108 $32398.0400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 3.233333 $80.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 69 116.294444 $5814.7200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 69 198.748410 $9937.4100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 51 60 122.322223 $6116.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.644444 $66.1100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 23 34 90.027778 $6600.8400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 31 39 167.003172 $4175.0900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 907 1449 16187.591234 $809379.5700 $50.0000
INTR -T1013 INTERPRETER 3 5 34.666667 $1733.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 950 2066 18508.653923 $185086.5400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 55 478.561900 $34188.4500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 8 63.500000 $3632.1900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 33 37 433.471425 $30967.2000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 39.000000 $2229.2400 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 1.716666 $111.5800 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.833333 $1291.9800 $455.9900
SENS -V5264 EARMOLD 3 4 6.572222 $118.3000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 42 435.557143 $31116.1900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 4.933333 $68.4700 $13.8800
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Subtotal (Total Children Is Unduplicated) 956 4376 37663.472123 $1291010.6500 $34.2800
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Total 4742 38215.553072 $1317957.3400 $34.4900
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Number of Children (Unduplicated) With at Least One Authorization 961