Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 6182 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 48 49 149.608727 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 484 502 14097.139679 $521594.2100 $37.0000
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Subtotal (Total Children Is Unduplicated) 490 551 14246.748406 $521594.2100 $36.6100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 18 12.002130 $582.1000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 2.000000 $169.6800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 9 9 5.783334 $295.3600 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.711111 $11.8800 $16.7000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.533333 $176.3300 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 209 212 416.750000 $20837.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 12 12 22.000000 $1650.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 28 45 58.566666 $4392.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 16 23.957143 $1329.6200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 137 138 226.500000 $16987.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 27.000000 $2025.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 25 25 44.500000 $3337.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 323 332 582.500000 $32328.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 256 320 542.000000 $40650.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 7 2.534245 $129.3800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 5.000000 $255.2500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 10.428571 $532.3800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 5.783561 $295.2500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 4.000000 $195.7600 $48.9400
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Subtotal (Total Children Is Unduplicated) 691 1185 2013.550094 $127380.0500 $63.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 15 7.985692 $39928.0000 $4999.9400
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.911111 $95.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 9.428571 $471.4300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 18 18 24.198412 $5565.6300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 236 260 302.860787 $15143.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 5.000000 $125.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 85 95 193.700007 $9685.0400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 3.816667 $95.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 25 57.560318 $2878.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 46 69.788890 $3489.4500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.566667 $39.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 55 57 83.655555 $4182.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.133334 $53.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 688 762 4734.023793 $236701.2700 $50.0000
INTR -T1013 INTERPRETER 127 142 360.716015 $18035.8100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 831 1288 6099.900097 $60999.0000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 23 201.404764 $14388.3400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 5.428571 $310.5200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 62 68 331.566665 $23687.1000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 8 9 50.831746 $2905.5500 $57.1600
SENS -V5264 EARMOLD 2 2 3.174429 $57.1400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 75 396.976187 $28359.9700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 4.285715 $59.4900 $13.8800
TRAV -TRAVS Travel by mile 957 1538 6421.659981 $2857.6400 $0.4400
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Subtotal (Total Children Is Unduplicated) 1023 4446 19373.573974 $470113.6600 $24.2700
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Total 6182 35633.872474 $1119087.9200 $31.4100
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Number of Children (Unduplicated) With at Least One Authorization 1274