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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2051 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 12 12 4.870244 $236.2100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.205479 $11.5300 $56.1100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 0.386301 $5.6700 $14.6800
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.172603 $19.9900 $115.8100
EXIT -EXIT EXIT ASSESSMENT 12 12 13.000000 $650.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 78 79 154.505479 $11587.9100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 30 30 59.500000 $4462.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 37 39 78.000000 $5850.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 19 19 37.500000 $2812.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 90 99 193.005479 $10711.8100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 9 10 20.000000 $1110.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 27 27 54.000000 $4050.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 10 12 22.500000 $1687.5000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 10 11 13.469047 $692.4400 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 8 5.317504 $273.3700 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.082192 $4.2300 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.082192 $4.2300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 2.614383 $134.4100 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.050000 $2.5700 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 8 8 3.349543 $172.2000 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 2.803956 $144.1500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 3 3 0.375343 $19.3000 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 1.657534 $85.2200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 9 4.448250 $228.6900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 20 21 12.378995 $636.4100 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.183333 $9.4200 $51.4000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.805556 $36.1400 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.272222 $12.2100 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 7.857143 $415.8800 $52.9300
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Subtotal (Total Children Is Unduplicated) 229 440 708.398334 $47086.0800 $66.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 16 17.619220 $88096.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.180822 $9.0400 $49.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 25 28.493017 $1424.6500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 5.005556 $250.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.966667 $49.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 142 160 247.217024 $12360.8400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.300000 $15.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 70 108.248859 $5412.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.300000 $7.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 15 20.666665 $1033.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 124 129 200.155117 $10007.7400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.133334 $78.3400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.857143 $842.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 126 130 815.585723 $40779.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 16 16 112.285713 $5614.3000 $50.0000
INTR -T1013 INTERPRETER 25 39 91.285715 $4564.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 201 394 1380.238824 $13802.3800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 36 260.428571 $18740.4300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.714286 $501.9400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 30 30 208.714286 $15019.0700 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 8.571429 $493.3700 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.345205 $79.2600 $229.6100
SENS -V5264 EARMOLD 1 1 0.517808 $9.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 41 280.857145 $20210.4800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 13.428571 $966.3200 $71.9600
TRAV -TRAVS Travel by mile 250 492 76795.373516 $34173.9400 $0.4500
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Subtotal (Total Children Is Unduplicated) 292 1611 80626.490216 $274541.5800 $3.4100
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Total 2051 81334.888550 $321627.6600 $3.9500
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Number of Children (Unduplicated) With at Least One Authorization 338