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: 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 1792 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 1 1 0.084932 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.084932 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 21 16.427473 $796.7300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.1600 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $47.0000 $23.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.722222 $32.5000 $45.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.494444 $24.7200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 27 27 26.473972 $1323.7100 $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 22 22 46.214286 $3466.0700 $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 93 97 171.994320 $9545.7000 $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 3 3 1.599392 $81.6500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.488889 $24.9600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 0.811416 $41.4300 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 11.405327 $582.2400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 1.243836 $63.5000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.914035 $199.8100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 5.725495 $292.2900 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.000000 $357.3500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 5.887520 $300.5600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.183333 $9.3600 $51.0400
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 11 3.797031 $169.1500 $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) 179 368 520.663025 $33041.0600 $63.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 25 27 32.019961 $160099.5000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.166667 $108.3400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.722222 $396.1100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 32 28.872223 $1443.6200 $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 160 177 380.080955 $19004.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.800000 $45.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 85 87 179.761906 $8988.1000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 6.133334 $306.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.733333 $18.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 46.871428 $2343.5700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.533333 $63.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 137 145 260.090478 $13004.5300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 5 5 5.666667 $283.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 165 170 1201.319036 $60066.0400 $50.0000
INTR -T1013 INTERPRETER 14 22 71.912393 $3595.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 162 284 1439.952368 $14399.5400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 37 332.428568 $23748.7300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 40.142856 $2867.8100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.214286 $69.4600 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 11.142857 $796.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 25 25 237.776190 $16986.7500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.642857 $403.1300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 25.852382 $1477.7200 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 35 324.428567 $23177.2200 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 6 6 61.857142 $858.5800 $13.8800
TRAV -TRAVS Travel by mile 169 323 76786.164792 $34169.8400 $0.4500
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Subtotal (Total Children Is Unduplicated) 208 1423 81501.042357 $389454.7000 $4.7800
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Total 1792 82021.790314 $422495.7600 $5.1500
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Number of Children (Unduplicated) With at Least One Authorization 250