Summary Report for FSPSAs Ending During the Report Period Center: 04
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 6615 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 145 179 287.379365 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 145 179 287.379365 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 5 22.215079 $1077.4300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 9 7.127778 $399.8700 $56.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 45 51 72.780953 $3741.6800 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.211111 $10.8500 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 16 17 11.222223 $576.9400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 5 5 2.433333 $125.1000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 52 72 117.513493 $6041.3800 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.722222 $37.1300 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 42 59 32.650793 $1678.5800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 20 23 15.366668 $790.0100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 7 8 3.022222 $155.3700 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 2 1.033334 $53.1300 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 3 3 2.205556 $113.3900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 39 57 25.233333 $1297.2400 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 27 38 44.839682 $2305.2100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 25 36 43.493652 $2236.0200 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 42 61 63.579362 $3268.6100 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 2 3 2.144444 $110.2400 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 4 5 3.300000 $169.6500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 21 12.483336 $641.7800 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 4 1.338889 $68.8300 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 15 20 7.833334 $402.7200 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.816667 $41.9900 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 7.714286 $396.5900 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 39.142857 $2012.3400 $51.4100
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Subtotal (Total Children Is Unduplicated) 215 504 540.424607 $27752.0700 $51.3500
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 2 2.000000 $138.7000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 60 219 155.660732 $7783.1200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 8 12 20.494444 $1024.7200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 5 11.011110 $275.2800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 26 52.918251 $2645.9000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 8 14.822220 $370.5500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.422222 $21.1100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.788889 $44.7200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 15 18.949204 $947.4600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.355555 $8.8900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 13 16 147.714285 $3692.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 191 443 4532.642858 $113316.0800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 7 86.142856 $4307.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 840 1181 17722.254773 $886112.7100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 726 1012 17577.327790 $878866.3300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1413 2165 35041.407163 $420496.8700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 113 1354.714284 $97485.2500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 25.857143 $1860.6800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 36 51 403.736902 $23255.2600 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 107 148 2018.689682 $145264.9000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 54 76 903.428573 $65010.7100 $71.9600
PHY -97110HM PT SESSION BY PT ASST 28 53 318.857143 $18353.4300 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 8.571429 $493.3700 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 63 93 1224.714286 $88130.4300 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 21.714286 $1562.5600 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 2 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 2 3 3.000000 $54.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 66 94 671.495635 $48320.8400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 93 147 1722.357139 $123940.8100 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 2 17.857142 $1285.0000 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 14 28 198.357142 $2769.0700 $13.9600
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Subtotal (Total Children Is Unduplicated) 1647 5932 84285.263138 $2939270.8000 $34.8700
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Total 6615 85113.067110 $2967022.8700 $34.8600
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Number of Children (Unduplicated) With at Least One Authorization 1720