Summary Report for FSPSAs Initiated During the Report Period Center: 04
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 6334 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 157 178 279.649203 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 157 178 279.649203 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 5.180953 $251.2800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 5.005555 $280.8100 $56.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 29 31 18.988889 $976.2200 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 16 16 11.722223 $602.6400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 4 4 2.416666 $124.2400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 27 33 71.903177 $3696.5500 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 64 91 48.439681 $2490.2800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 13 14 10.900000 $560.3700 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 6 6 2.427778 $124.8100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.805556 $41.4200 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 2 2 1.822223 $93.6800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 24 12.900001 $663.1900 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 44 66 66.438094 $3415.5800 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 19 23 17.745238 $912.2900 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 54 86 75.118254 $3861.8400 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 2 3 2.144444 $110.2400 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 5 6 4.227778 $217.3500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 12 7.516668 $386.4400 $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 7 7 3.955556 $203.3600 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 0.950000 $48.8400 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 3 46.000000 $2364.8600 $51.4100
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Subtotal (Total Children Is Unduplicated) 200 445 417.947623 $21495.1300 $51.4300
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 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 57 235 151.497629 $7574.9300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 12 15 26.632541 $1331.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 10.866666 $271.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 37 96.412696 $4820.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 10.499999 $262.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.355556 $17.7800 $50.0100
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.788889 $44.7200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 14 21.093649 $1054.6800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.355555 $8.8900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 9 9 106.999999 $2675.0100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 193 458 4810.071415 $120251.8100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 3 49.714285 $2485.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 480 580 10923.071412 $546153.6100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1071 1520 24635.519014 $1231776.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1442 2063 35178.711853 $422144.6000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 59 815.285711 $58667.9800 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 25.857143 $1860.6800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 12 15 116.357141 $6702.1800 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 132 210 2704.832540 $194639.7800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 32 41 576.357143 $41474.6600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 13 25 113.214284 $6516.6300 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 79 142 1604.642855 $115470.1500 $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 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 2 2 2.000000 $36.2600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 46 369.142857 $26563.5400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 105 198 2078.357140 $149558.6100 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 3 19.499999 $1403.2300 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 10 14 114.642856 $1600.4200 $13.9600
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Subtotal (Total Children Is Unduplicated) 1670 5711 84591.495113 $2948202.3800 $34.8500
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Total 6334 85289.091939 $2969697.5100 $34.8200
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Number of Children (Unduplicated) With at Least One Authorization 1751