Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2736 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 34 13.906774 $674.4800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.033333 $18.5200 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.221918 $4.7400 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 0.560807 $7.0700 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.221918 $1.8300 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.221918 $5.6200 $25.3100
EXIT -EXIT EXIT ASSESSMENT 48 49 73.355970 $3667.8000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 2.010958 $150.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 6.010958 $333.6100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 86 86 121.658894 $9124.4600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 51 51 77.065748 $5779.9500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 94 95 134.647933 $7472.9900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 38 38 66.027395 $4952.0600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.178082 $60.1400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 0.586302 $29.9300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 16 17 4.928539 $251.5900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.454566 $23.2100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 1.630289 $83.2300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.265754 $64.6100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 20 20 4.739118 $241.9300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 3.654793 $186.5700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 9 9 4.499412 $229.6900 $51.0500
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Subtotal (Total Children Is Unduplicated) 238 454 529.892337 $34067.7700 $64.2900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 33 13.653198 $68267.0000 $5000.0700
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.221918 $51.0400 $229.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 44 48 25.747393 $1287.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.255556 $31.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 209 246 429.755126 $21487.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 5.100000 $127.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 68 99.766667 $4988.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.450000 $111.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 25 40.700000 $2035.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 153 156 229.366674 $11468.3700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.383333 $34.5800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 22.999997 $1686.3700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 13 13 376.428569 $9410.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 236 250 1468.047617 $73402.3700 $50.0000
INTR -T1013 INTERPRETER 29 46 114.879060 $5743.9500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 274 453 1778.544178 $17785.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 44 349.714285 $24983.5800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 52 55 375.087997 $26796.2900 $71.4400
SENS -V5264 EARMOLD 1 1 0.221918 $3.9900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 49 49 392.176258 $28017.0700 $71.4400
TRAV -TRAVS Travel by mile 319 776 131804.866088 $58653.1700 $0.4500
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Subtotal (Total Children Is Unduplicated) 343 2282 137534.365832 $356372.5200 $2.5900
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Total 2736 138064.258169 $390440.2900 $2.8300
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Number of Children (Unduplicated) With at Least One Authorization 358