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: 07-01-19 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 1114 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 2 2 0.422222 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 2.733333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 4.657143 $172.3100 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 7.812698 $172.3100 $22.0600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 1.200608 $58.2300 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 0.955555 $13.2500 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 16 6.944446 $164.5900 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.427778 $19.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.427778 $49.2000 $115.0100
EXIT -EXIT EXIT ASSESSMENT 2 2 2.750000 $137.5000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 4.299999 $215.0000 $50.0000
SCREEN-T1023 SCREENING 1 1 3.857143 $192.8600 $50.0000
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Subtotal (Total Children Is Unduplicated) 30 32 22.863307 $960.8700 $42.0300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 4.000000 $20000.0000 $5000.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 3.000000 $214.8300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 4.116667 $946.8400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 23 23.061111 $1153.0600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 19 20 18.160318 $908.0200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 37 39.983334 $1999.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.857143 $21.4300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 37 42.744446 $2137.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 15.884921 $794.2500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.666667 $66.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 19 30 67.260316 $1681.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 275 308 1251.823031 $62591.1600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 363 521 1724.840657 $17248.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 30 128.530953 $9182.2500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 12.866667 $735.9800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 21 22 77.109524 $5508.7000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 15.866667 $906.9400 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 13 49.980953 $3570.6400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 7.571429 $105.0900 $13.8800
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Subtotal (Total Children Is Unduplicated) 370 1077 3490.324804 $129772.1400 $37.1800
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Total 1114 3521.000809 $130905.3200 $37.1800
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Number of Children (Unduplicated) With at Least One Authorization 377