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: 07-01-22 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 8314 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 59 81 58.086304 $2817.2000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 6 3.108904 $174.4000 $56.1000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 11 7.739726 $113.6200 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 6 5.078996 $112.0900 $22.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 3.311111 $150.0600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.849315 $98.3600 $115.8100
EXIT -EXIT EXIT ASSESSMENT 69 70 85.562755 $4278.1300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $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 4 4 5.005479 $277.8100 $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 269 275 465.644404 $34923.4000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 114 120 229.510958 $17213.3300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 90 92 181.500000 $13612.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 45 46 89.500000 $6712.5000 $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 326 360 620.241076 $34423.4300 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 66 70 136.500000 $7575.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 79 83 157.500000 $11812.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 32 36 70.000000 $5250.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 2 9.700000 $485.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 1.688889 $86.8300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 30 39 76.803948 $3948.5000 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.594444 $30.5600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 31 36 24.020700 $1234.9000 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 35.282974 $1813.8900 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.498630 $25.6300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 30 39 18.916971 $972.5200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 2 1.361111 $69.9700 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 4 1.577778 $81.1100 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 20.834127 $1071.0900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 6 3.889879 $199.9800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 24 31 49.678691 $2553.9900 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.501370 $25.7800 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 27 33 24.914841 $1280.8800 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 5 5 2.408219 $123.8000 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 35 42 16.158906 $830.7300 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.498630 $25.6300 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 3 1.854262 $95.3300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 32 39 85.506393 $4395.8900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.972222 $49.9800 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.672222 $34.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 9 7.866134 $404.4000 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 57 71 56.113884 $2884.8200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 2.905556 $149.3800 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 2 1.205556 $61.9800 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.164307 $59.8600 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 4 2.316667 $119.1000 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 12 7.489346 $385.0300 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.356545 $69.7400 $51.4100
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.532877 $27.4000 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 5 6 113.857142 $5853.4000 $51.4100
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Subtotal (Total Children Is Unduplicated) 717 1684 2712.287728 $170410.9600 $62.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 66 95 325.476204 $1627382.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 4.398630 $219.9300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 2 0.432877 $30.0200 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 5 4.743988 $1098.8100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 96 112 178.150983 $8907.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 10 14.016667 $700.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 13.050000 $326.2500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 420 683 2898.493225 $144924.7200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 4 10.066666 $503.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 199 300 1282.493874 $64124.7300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 4.133334 $206.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 17.633333 $440.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 64 295.111907 $14755.6100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 379 560 2283.888466 $114194.4800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 5 6 17.900001 $895.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 9 35.000001 $875.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 9 12 202.933333 $10146.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 399 594 9726.557138 $486327.8800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 48 58 1075.214284 $53760.7100 $50.0000
INTR -T1013 INTERPRETER 52 107 418.390376 $20919.5100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 566 1553 14926.854530 $179122.2700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 110 151 2822.671426 $203119.4300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 3 68.428572 $4924.1200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 3 4 48.571429 $2797.7100 $57.6000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 8.000000 $575.6800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 103 145 2855.296824 $205467.1500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 3 39.714286 $2285.9600 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 2 4 3.353424 $769.9700 $229.6100
SENS -V5264 EARMOLD 2 4 4.030137 $73.0700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 122 161 2856.028572 $205519.8000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 5 81.428571 $5859.5900 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 2 42.571429 $594.3000 $13.9600
TRAV -TRAVS Travel by mile 733 1961 794087.231412 $353368.8200 $0.4500
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Subtotal (Total Children Is Unduplicated) 794 6630 836652.265899 $3715218.4100 $4.4400
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Total 8314 839364.553627 $3885629.3700 $4.6300
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Number of Children (Unduplicated) With at Least One Authorization 892