Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 4093 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 2 2 5.377778 $198.9800 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 47 49 190.102381 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 15 15 356.480952 $13189.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 63 66 551.961111 $13388.7800 $24.2600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 27 24.286303 $1177.8900 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.7100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.4900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.933333 $45.8200 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $9.0800 $9.0800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 2.000000 $169.6800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $16.7000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
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 24 24 43.000000 $3225.0000 $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 129 130 244.000000 $13542.0000 $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 184 259 491.000000 $36825.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 2.202740 $112.4500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.285714 $116.6900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 10 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 3.000000 $133.6500 $44.5500
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Subtotal (Total Children Is Unduplicated) 346 597 1071.762885 $69379.9500 $64.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 20 20.472299 $102361.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 3 1.405556 $70.2800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 9.000000 $2070.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 191 219 287.406414 $14370.3300 $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 135 148 137.461349 $3436.5400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 104 116 229.132538 $11456.6200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 8 13.166667 $329.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 38 41 66.394445 $3319.7300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.433334 $135.8400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 52 57 92.735713 $4636.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 8.142857 $203.5700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 80 86 139.507936 $6975.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.300001 $182.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 535 572 3708.841250 $185442.1500 $50.0000
INTR -T1013 INTERPRETER 70 83 246.424604 $12321.2300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 643 935 5113.915056 $51139.1700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 41 295.733333 $21127.1700 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.900000 $135.7400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 54 58 359.238889 $25664.0400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.714286 $408.2300 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 4 5 22.857142 $1632.9100 $71.4400
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 79 479.128568 $34228.9500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 22.142857 $1581.8900 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 7.000000 $500.0800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 17.714286 $1265.5100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 29.857143 $414.4200 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 9.000000 $333.0000 $37.0000
TRAV -TRAVS Travel by mile 644 929 5075.096010 $2258.4200 $0.4500
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Subtotal (Total Children Is Unduplicated) 694 3430 16415.122533 $488087.1400 $29.7300
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Total 4093 18038.846529 $570855.8700 $31.6500
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Number of Children (Unduplicated) With at Least One Authorization 780