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: 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 8412 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 12.052381 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 12.052381 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 57 79 53.306394 $2585.3600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 6 3.257534 $182.7500 $56.1000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 7 4.427397 $64.9900 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.153425 $3.3900 $22.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 3.043378 $137.9200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 1.057535 $122.4700 $115.8100
EXIT -EXIT EXIT ASSESSMENT 61 62 79.233988 $3961.6900 $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 269 276 475.711071 $35678.4000 $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 89 91 179.500000 $13462.5000 $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 327 361 622.241076 $34534.4300 $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 78 80 151.500000 $11362.5000 $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 1 6.100000 $305.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 43 55 65.546347 $3369.7400 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.988888 $50.8300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 32 38 23.191627 $1192.2800 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 4 6 48.347554 $2485.5400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.142466 $7.3300 $51.4200
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 3 24.198043 $1244.0200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 24 12.285616 $631.6000 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.433333 $22.2800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 3 1.238889 $63.6900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 7 3.760427 $193.3300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 32 42 60.528787 $3111.7900 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.501370 $25.7800 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 23 27 20.398706 $1048.7000 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 5 8 3.520549 $180.9800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 16 17 9.416362 $484.0900 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.498630 $25.6300 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.926484 $47.6300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 48 60 72.552360 $3729.9300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 1.366666 $70.2600 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.672222 $34.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 4.432192 $227.8600 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.106849 $5.4900 $51.3900
SPCH -92522TL EVAL OF SPCH SOUND PROD 3 3 1.556165 $80.0000 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 48 57 42.516285 $2185.7600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 7.515688 $386.3900 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.316667 $16.2800 $51.4200
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.727778 $37.4200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 7 4.383562 $225.3600 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 4 2.127093 $109.3500 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 4 93.571428 $4810.5100 $51.4100
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Subtotal (Total Children Is Unduplicated) 664 1646 2636.822747 $166870.2600 $63.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 66 90 399.397077 $1996985.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.498630 $24.9300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.358904 $24.8900 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 3 3.125570 $723.9300 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 100 120 223.393840 $11169.7000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 8 9 13.016667 $650.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 13.050000 $326.2500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 429 665 2856.281322 $142814.1200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 7.900000 $395.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 226 315 1307.218679 $65360.9400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 4 12.333333 $616.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 5 23.066667 $576.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 56 257.878576 $12893.9500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 405 562 2277.551159 $113877.5900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 8.100000 $405.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 23.266668 $581.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 13 16 222.504762 $11125.2400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 381 542 9110.646798 $455532.4500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 65 84 1360.857138 $68042.8700 $50.0000
INTR -T1013 INTERPRETER 50 105 349.890375 $17494.5200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 529 1608 14990.075928 $179880.9500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 122 163 2913.877776 $209682.6500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 47.714286 $3433.5200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 11.142857 $641.8300 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 94 125 2548.607930 $183397.8300 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 26.142857 $1504.7900 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 2 3 3.008219 $690.7100 $229.6100
SENS -V5264 EARMOLD 2 3 3.512329 $63.6800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 133 165 2983.814281 $214715.3100 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 8 114.285714 $8224.0000 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 2 35.571429 $496.5800 $13.9600
TRAV -TRAVS Travel by mile 660 2089 827216.870698 $368111.5100 $0.4500
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Subtotal (Total Children Is Unduplicated) 704 6764 869366.960469 $4070516.0700 $4.6800
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Total 8412 872015.835597 $4237386.3300 $4.8600
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Number of Children (Unduplicated) With at Least One Authorization 780