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: 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 4487 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 7 7 6.585714 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 32.738096 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 40 40 133.633336 $4944.4400 $37.0000
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Subtotal (Total Children Is Unduplicated) 51 51 172.957146 $4944.4400 $28.5900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 13 11.983334 $581.1900 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 26 30 23.838893 $330.6500 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 46 48 47.644440 $1129.1600 $23.7000
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.366667 $22.8200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 24.857143 $556.8000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 2.227777 $100.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 2.227777 $256.1900 $115.0000
EXIT -EXIT EXIT ASSESSMENT 5 5 6.866667 $343.3400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 31 43.255556 $3244.1700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 29 46 68.794446 $5159.6000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 14 23 32.772221 $2457.9100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 21 36 63.133334 $3503.9000 $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
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 3.550000 $177.5000 $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) 142 260 361.518255 $19575.7800 $54.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 22 20.000001 $100000.5000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.933333 $96.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.055556 $147.2000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 32 34 45.811111 $10536.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 63 74 56.346032 $2817.3000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 116 160 450.562701 $22528.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 82 161.061111 $8053.0600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 104 290.060316 $14503.0200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 58 73 141.000001 $7050.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.922222 $123.0600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 23 33 94.050002 $6895.7600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 30 36 166.031740 $4150.8100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 861 1316 14968.511107 $748425.4400 $50.0000
INTR -T1013 INTERPRETER 2 2 26.333334 $1316.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 945 1979 18126.108727 $181261.0600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 66 81 723.130946 $51660.4500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 8 43.395237 $2482.2000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 63 79 800.880952 $57214.9200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 4 50.704762 $2898.2800 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 2 1.205555 $78.3600 $65.0000
SENS -V5264 EARMOLD 1 2 2.411111 $43.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 73 587.047623 $41938.6500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 8.790476 $122.0100 $13.8800
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Subtotal (Total Children Is Unduplicated) 957 4176 36774.353956 $1264418.5000 $34.3800
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Total 4487 37308.829357 $1288938.7200 $34.5500
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Number of Children (Unduplicated) With at Least One Authorization 961