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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4431 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 3 3 4.533333 $167.7300 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 59 60 144.220630 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 62 63 148.753963 $167.7300 $1.1300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 21 28.620156 $1388.0700 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $20.8900 $20.8900
EXIT -EXIT EXIT ASSESSMENT 26 26 52.000000 $2600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 20.000000 $1110.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 158 159 313.500000 $23512.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 23 23 45.000000 $3375.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 91 91 176.500000 $13237.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 7 7 13.500000 $1012.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 320 323 628.285714 $34869.8600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 17 17 34.000000 $1887.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 153 163 312.928571 $23469.6500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 16 16 31.500000 $2362.5000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 7.857143 $401.1100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 7.000000 $357.3500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 0.421918 $21.5400 $51.0600
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.158904 $7.0800 $44.5800
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.428571 $337.9500 $52.5700
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Subtotal (Total Children Is Unduplicated) 487 915 1747.700977 $114911.7300 $65.7500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 19 26.311938 $131560.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 11 11 12.000000 $2760.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 234 258 291.099022 $14554.9500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 16 1.557535 $77.8700 $49.9900
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 30 31 28.862623 $721.5600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 104 121 231.852384 $11592.6400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 8 8 15.844445 $792.2300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.266667 $6.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 35 63.511902 $3175.5900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 6.744445 $337.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 46 90.661902 $4533.0900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 3 3 6.233334 $311.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.466666 $61.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 77 84 150.311905 $7515.6000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 8 8.744446 $437.2300 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.000000 $50.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 591 639 4071.338103 $203566.7400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 28 33 167.961909 $8398.0900 $50.0000
INTR -T1013 INTERPRETER 118 133 370.307141 $18515.3500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 683 930 5339.920427 $53399.1600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 16 119.704762 $8551.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 55 57 371.861911 $26565.7900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 4 34.714285 $2479.9900 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 5 5 54.000000 $3857.7500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 42 45 271.828572 $19419.4300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.428571 $316.3800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 16.857143 $1204.2700 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 5 5 23.857144 $331.1400 $13.8800
TRAV -TRAVS Travel by mile 691 933 5307.744239 $2361.9400 $0.4400
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Subtotal (Total Children Is Unduplicated) 829 3453 17094.993421 $527624.5600 $30.8600
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Total 4431 18991.448361 $642704.0200 $33.8400
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Number of Children (Unduplicated) With at Least One Authorization 1168