Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1850 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 21 23 17.775571 $862.1200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.5800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.038356 $24.4000 $23.5000
EXIT -EXIT EXIT ASSESSMENT 32 32 38.285714 $1914.2900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 76 76 129.280034 $9696.0200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 48.214286 $3616.0700 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.500000 $337.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 94 98 173.994320 $9656.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.500000 $83.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 26 29 58.000000 $4350.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.008219 $0.4200 $50.9300
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 2.327778 $118.8300 $51.0500
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.022222 $1.1300 $51.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 2.896195 $147.8500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 21 21 15.944141 $813.9500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.008219 $0.4200 $50.9300
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 3.626865 $185.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 4.169026 $212.8300 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.000000 $204.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 9.688509 $494.6000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.305556 $15.6000 $51.0600
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 2.533030 $112.8500 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 205 372 536.118041 $33947.0800 $63.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 25 27 23.042911 $115214.0000 $4999.9800
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 32 25.313775 $1265.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 4 5 7.000000 $350.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.755556 $68.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 157 186 281.155950 $14057.7900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 79 84 124.647619 $6232.3800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 16 16 25.709525 $1285.4900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.333333 $58.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 20.814288 $1040.7300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.733333 $118.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 154 239.833330 $11991.6500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 5.066667 $253.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.033333 $0.8300 $24.9800
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 165 175 1062.857146 $53142.8500 $50.0000
INTR -T1013 INTERPRETER 14 21 48.340964 $2417.0500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 168 291 1248.457148 $12484.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 39 246.542859 $17613.0100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 6 6 38.857143 $2775.9700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 20.142857 $1152.1700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 25 25 161.971430 $11571.2400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 6.000000 $428.6400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.571429 $32.6600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 44 44 281.361906 $20100.4900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 12.620635 $901.6200 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 18.428572 $255.7900 $13.8800
TRAV -TRAVS Travel by mile 184 336 65589.253753 $29187.2200 $0.4500
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Subtotal (Total Children Is Unduplicated) 237 1478 69499.845462 $304299.5700 $4.3800
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Total 1850 70035.963503 $338246.6400 $4.8300
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Number of Children (Unduplicated) With at Least One Authorization 313