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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2269 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 24 24 11.136757 $540.1300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.139726 $16.7300 $14.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.744444 $33.7400 $45.3200
EXIT -EXIT EXIT ASSESSMENT 18 18 17.569407 $878.4700 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 71 75 122.274555 $9170.6100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 27 31 59.000000 $4425.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 32 32 61.500000 $4612.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 21 22 42.000000 $3150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 70 84 141.060269 $7828.8600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 18 20 39.000000 $2164.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 22 36.500000 $2737.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 9 11 21.500000 $1612.5000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 17 17 6.825340 $350.8800 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.394444 $20.2800 $51.4000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 1.914079 $98.4000 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 12.650881 $650.3800 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.142466 $7.3300 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 2.064687 $106.1500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.453881 $23.3300 $51.4000
PSTH -97161 PT EVAL LOW COMPLEXITY 11 11 9.668438 $497.0600 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 2.127549 $109.3700 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.538660 $27.6900 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 17 18 13.921567 $715.7100 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.394444 $20.2800 $51.4000
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.106849 $5.4900 $51.3900
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.142466 $7.3300 $51.4200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 5.445205 $279.9400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 4.142857 $212.9900 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.878006 $45.1400 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.120548 $6.1900 $51.3900
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 12.571429 $646.3000 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 209 435 631.928954 $41230.5200 $65.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 24 45.496466 $227482.0000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.744444 $172.4200 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 31 40.200679 $2010.0400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 2 2 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.750000 $18.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 151 170 292.183332 $14609.1600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.266667 $63.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 87 88 146.220630 $7311.0100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 1.033333 $51.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.966667 $49.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 21.533334 $1076.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 146 151 258.181745 $12909.0900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.966667 $124.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 31.714286 $1585.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 130 131 916.446818 $45822.3800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 28 28 184.999996 $9250.0200 $50.0000
INTR -T1013 INTERPRETER 10 19 43.057988 $2152.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 184 444 1737.332449 $20848.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 43 287.187300 $20666.0100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 9.000000 $647.6400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 27 27 195.387300 $14060.0800 $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 35 36 237.999999 $17126.4900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 6.428571 $462.6000 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 9.571429 $133.6200 $13.9600
TRAV -TRAVS Travel by mile 230 607 102812.749399 $45751.6800 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 245 1834 107293.419499 $444832.3300 $4.1500
-------------------------------------------------------------------------------------------------------------------------------------
Total 2269 107925.348453 $486062.8500 $4.5000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 276