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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4399 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 50 52 98.756350 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 19 19 536.955557 $19867.3500 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 67 71 635.711907 $19867.3500 $31.2500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 28 20.838356 $1010.6600 $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 3 3 3.450000 $81.7700 $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 144 146 292.000000 $14600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 18 33.500000 $2512.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.500000 $262.5000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 26 39 72.500000 $5437.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 14 27.500000 $1526.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 151 151 290.000000 $21750.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 54 54 104.000000 $7800.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 5.000000 $375.0000 $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 212 213 406.000000 $22533.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $444.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 183 204 387.133334 $29035.0100 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 13.000000 $975.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 3.320548 $169.5100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 10.714285 $546.9700 $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 9 4.802740 $245.1800 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 3.714286 $189.6200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 542 944 1745.973549 $113161.8800 $64.8100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 19 14.946195 $74731.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.405556 $20.2800 $50.0100
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 8.000000 $1840.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 223 262 309.588204 $15479.4000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 6 1.526026 $76.3100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 46 51 41.815069 $1045.3800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 99 112 196.452380 $9822.6200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.000000 $100.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 8.200000 $205.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 40 45 75.677774 $3783.8700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 13.309524 $332.7400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 50 78.290479 $3914.5400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.000000 $125.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 82 85 136.267458 $6813.3700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.700000 $92.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 483 512 2921.890489 $146094.5200 $50.0000
INTR -T1013 INTERPRETER 135 158 412.665103 $20633.2700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 612 937 4426.488916 $44264.8900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 38 169.552385 $12112.8200 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 8.571428 $612.3500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.266667 $233.3700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 53 54 329.495242 $23539.1300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.266667 $301.0400 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 10.571428 $755.2300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 76 488.780956 $34918.5400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 17.333333 $1238.2900 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 6.857143 $489.8700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 19.714286 $1408.3900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 60.571429 $840.7300 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.571429 $77.3300 $13.8800
TRAV -TRAVS Travel by mile 616 937 4398.760347 $1957.4500 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 740 3384 14180.535913 $407859.2100 $28.7600
-------------------------------------------------------------------------------------------------------------------------------------
Total 4399 16562.221369 $540888.4400 $32.6600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1021