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: 04-01-20 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 4835 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.166667 $6.1700 $37.0100
SCONLY-SCONLY *SERVICE COORDINATION ONLY 70 73 243.553969 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 428 429 8283.795256 $306500.4400 $37.0000
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Subtotal (Total Children Is Unduplicated) 475 503 8527.515892 $306506.6100 $35.9400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 20 16.660274 $808.0200 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 7 7 7.000000 $593.8800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $102.1400 $51.0700
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 82 82 164.000000 $8200.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 7.500000 $562.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 6.500000 $360.7500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 25 25 44.500000 $3337.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 8 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 132 133 249.500000 $13847.2500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 186 261 495.000000 $37125.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 8.000000 $408.4000 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 8.000000 $408.4000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 8.054795 $411.2000 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 9.000000 $400.9500 $44.5500
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Subtotal (Total Children Is Unduplicated) 357 600 1091.715069 $71034.5900 $65.0700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 14 13.162176 $65810.5000 $4999.9700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.033333 $1.6700 $49.9500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 5.711111 $285.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 9.688889 $2228.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 197 225 291.795302 $14589.7700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 136 149 138.961349 $3474.0400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 84 98 170.087303 $8504.3800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 5 6.133333 $153.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 40 57.683332 $2884.1600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.500000 $12.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 52 78.666666 $3933.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 83 118.211109 $5910.5500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 617 675 3814.657127 $190732.8500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 30.580952 $1529.0600 $50.0000
INTR -T1013 INTERPRETER 73 85 257.915079 $12895.7600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 737 1050 5035.965857 $50359.6600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 36 187.100001 $13366.4400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 51 56 304.914286 $21783.0600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.714286 $408.2300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.933333 $224.8300 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.285714 $377.6100 $71.4400
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 82 89 497.187299 $35519.0500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.285714 $306.1700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 33.857143 $469.9400 $13.8800
TRAV -TRAVS Travel by mile 733 1044 5014.470618 $2231.4400 $0.4400
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Subtotal (Total Children Is Unduplicated) 813 3732 16089.501312 $438078.2800 $27.2300
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Total 4835 25708.732273 $815619.4800 $31.7300
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Number of Children (Unduplicated) With at Least One Authorization 1058