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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1873 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 16 16 10.801979 $523.9000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.6800 $14.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.755556 $34.2400 $45.3200
EXIT -EXIT EXIT ASSESSMENT 15 15 16.002740 $800.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.005479 $111.3100 $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 54 54 91.543832 $6865.8000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 28 29 55.500000 $4162.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 22 44.000000 $3300.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 63 64 110.543832 $6135.1900 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 22 22 41.500000 $2303.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 17.000000 $1275.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 16.000000 $1200.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 2.533333 $126.6700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 4.982725 $256.1600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 14 15 3.637063 $186.9800 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.167123 $8.5900 $51.4000
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 2.374885 $122.0900 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.094444 $4.8500 $51.3900
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.055556 $2.8600 $51.4500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.483333 $24.8500 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 12 12 4.873593 $250.5500 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.202740 $10.4200 $51.4000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 12 13 5.659133 $290.9400 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 0.249315 $12.8200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 0.733181 $37.6900 $51.4000
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.126027 $6.4800 $51.4000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.310882 $15.9800 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 3.028006 $155.6600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 1.422222 $73.1200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 20 9.992694 $513.7200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.088889 $55.9800 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.133333 $6.8500 $51.4000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.555556 $24.9200 $44.8600
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Subtotal (Total Children Is Unduplicated) 167 361 470.362930 $30431.7000 $64.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 21 53.887355 $269436.0000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.755556 $175.0100 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 27 35.477487 $1773.8800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 3.500000 $175.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 144 153 265.509525 $13275.4900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 2.633333 $131.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 68 120.071430 $6003.5800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 2.000000 $100.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.800000 $45.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 19.449999 $972.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 133 134 224.504764 $11225.2500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 2.666667 $133.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.533333 $63.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 55.285715 $2764.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 122 125 858.400002 $42919.9800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 23 161.142854 $8057.1500 $50.0000
INTR -T1013 INTERPRETER 19 31 75.969765 $3798.4900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 169 356 1509.119767 $15091.2000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 39 343.114286 $24690.5200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.428571 $174.7600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.428571 $139.8900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 39 39 312.857141 $22513.2000 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 38 262.428571 $18884.3700 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 9.714286 $135.6100 $13.9600
TRAV -TRAVS Travel by mile 183 421 81429.197852 $36235.9900 $0.4500
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Subtotal (Total Children Is Unduplicated) 215 1512 85758.876830 $479163.1900 $5.5900
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Total 1873 86229.239760 $509594.8900 $5.9100
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Number of Children (Unduplicated) With at Least One Authorization 243