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: 07-01-19 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4190 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 12 12 16.855555 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 16.333333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 31 31 70.003175 $2590.1200 $37.0000
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Subtotal (Total Children Is Unduplicated) 45 45 103.192063 $2590.1200 $25.1000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 6.409666 $310.8700 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 19 19 10.900001 $151.1800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 49 51 44.666665 $1058.6000 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.216667 $54.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.216667 $139.9200 $115.0000
EXIT -EXIT EXIT ASSESSMENT 7 7 11.594444 $579.7200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.622222 $271.6700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 1.955555 $146.6600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 3.727778 $279.5900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.694444 $205.0400 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 20.433332 $1021.6600 $50.0000
SCREEN-T1023 SCREENING 1 1 13.214286 $660.7200 $50.0000
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Subtotal (Total Children Is Unduplicated) 89 105 124.651727 $4991.3700 $40.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 6.005556 $30028.0000 $5000.0400
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.088889 $4.4500 $50.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 3.000000 $214.8300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 18 18 13.577779 $3122.9200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 53 62 55.424604 $2771.2400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 4.500000 $112.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 56 64 149.018253 $7450.9100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 87 110 246.617460 $12330.8800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 34.331746 $858.3000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 103 244.619837 $12230.9700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.711111 $35.5600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.500000 $12.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 57 67 135.865079 $6793.2600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 3 3 5.655556 $282.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 13.033333 $325.8300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 16.233333 $1190.2300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 53 101 471.569841 $11789.2600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 6.650000 $332.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 751 1158 11946.346821 $597317.4800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 31.942857 $1597.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 917 1931 16997.617719 $169976.2100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 77 112 1106.583325 $79054.3000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 29.380952 $2098.9700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 10 126.938096 $7260.8600 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 21.033333 $1502.6200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 79 121 1529.466662 $109265.1200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 6.133333 $438.1600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 33.019047 $1887.3700 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 11.295238 $806.9400 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.377778 $24.5600 $65.0000
SENS -V5264 EARMOLD 1 1 0.755556 $13.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 79 102 988.512700 $70619.3600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 9.766666 $697.7300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 10.450000 $746.5500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 52.685714 $731.2800 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.285714 $31.7300 $13.8800
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Subtotal (Total Children Is Unduplicated) 929 4040 34312.999444 $1134007.1400 $33.0500
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Total 4190 34540.843234 $1141588.6200 $33.0500
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Number of Children (Unduplicated) With at Least One Authorization 941