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: 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 4473 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 1 1 9.000000 $333.0000 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 63 65 156.143650 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 64 66 165.143650 $333.0000 $2.0200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 18 15.547945 $754.0800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $23.5000 $23.5000
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 158 160 316.785714 $23758.9300 $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 -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $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 -92521 EVAL OF SPEECH FLUENCY 3 3 4.000000 $204.2000 $51.0500
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 8.068493 $411.9000 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.320548 $16.3700 $51.0600
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.221918 $9.8900 $44.5700
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 9 9 53.555555 $2815.4200 $52.5700
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Subtotal (Total Children Is Unduplicated) 494 931 1793.214458 $117357.1200 $65.4500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 17 10.049315 $50247.0000 $5000.0400
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 4.000000 $200.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 15.285714 $3515.7100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 231 255 287.865688 $14393.2800 $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 34 35 34.829290 $870.7300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 114 123 214.446029 $10722.2900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 15 15 20.027777 $1001.3900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 9.733333 $243.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 49 76.311107 $3815.5400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 0.611111 $30.5600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 9.519047 $237.9800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 46 57.916668 $2895.8400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 6 6 4.433332 $221.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 6.933333 $173.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 77 81 121.869050 $6093.4700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 11 12 13.727777 $686.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 5.366667 $134.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 10 10 7.466665 $373.3500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 602 636 4037.776136 $201888.9500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 35 38 136.557140 $6827.8600 $50.0000
INTR -T1013 INTERPRETER 114 130 314.935715 $15746.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 701 918 5074.033798 $50740.3800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 23 97.252381 $6947.7300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 50 53 304.500002 $21753.4700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.428571 $102.0600 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 7.571429 $540.9000 $71.4400
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 42 44 280.742853 $20056.3000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 8.428571 $602.1400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.000000 $71.4400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 7 7 42.857142 $3061.7200 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 27.714285 $384.6700 $13.8800
TRAV -TRAVS Travel by mile 704 927 5077.157605 $2259.3300 $0.4400
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Subtotal (Total Children Is Unduplicated) 803 3476 16315.905066 $426953.5800 $26.1700
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Total 4473 18274.263174 $544643.7000 $29.8000
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Number of Children (Unduplicated) With at Least One Authorization 932