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 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 3737 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 19 19 22.111110 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 12.333333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 15.480953 $572.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 22 22 49.925396 $572.8000 $11.4700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 9 7.481888 $362.8700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 8 8 5.566667 $77.2100 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 49 55 48.516666 $1149.8400 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.022222 $46.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.838889 $96.4700 $115.0000
EXIT -EXIT EXIT ASSESSMENT 7 7 11.594444 $579.7200 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 3.133333 $173.9000 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 18.399999 $920.0000 $50.0000
SCREEN-T1023 SCREENING 3 3 14.380953 $719.0500 $50.0000
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Subtotal (Total Children Is Unduplicated) 82 92 115.435061 $4405.0500 $38.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 4.277778 $21389.0000 $5000.0300
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 4.000000 $286.4400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 5.911111 $1359.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 52 62 54.269048 $2713.4600 $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 40 46 136.386509 $6819.3300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 9.857143 $246.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 102 126 298.350794 $14917.5500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 15 15 27.638888 $1381.9400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 33.059524 $826.4900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 79 201.093646 $10054.6600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 7 7 6.022223 $301.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.500000 $12.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 61 73 149.523017 $7476.1600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 17 18 18.522223 $926.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 9.777777 $244.4400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 45 93 455.357141 $11383.9400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 43.740476 $2187.0300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 664 981 11110.423010 $555521.2700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 104 107 597.114285 $29855.7300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 816 1582 15697.517730 $156975.2100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 106 1231.407139 $87971.7200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 8 8 50.628571 $3616.9000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 10 129.638096 $7415.3000 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 34.857143 $1993.8300 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 23.714286 $1694.1500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 9 9 54.271429 $3877.1600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 73 103 1386.969047 $99085.0900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 11 11 99.166667 $7084.4700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 58.876190 $3365.3600 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 6.866667 $392.5000 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 12 13 50.695238 $3621.6700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 65 86 863.261906 $61671.4400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 13 13 62.214285 $4444.5800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 19 20 97.259523 $6948.2300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 36.190476 $502.3200 $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) 926 3623 33057.150256 $1118757.5500 $33.8400
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Total 3737 33222.510713 $1123735.4000 $33.8200
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Number of Children (Unduplicated) With at Least One Authorization 938