Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4834 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 78 80 151.279363 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.377778 $14.0500 $37.2000
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Subtotal (Total Children Is Unduplicated) 79 81 151.657141 $14.0500 $0.0900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 19 14.711416 $713.5000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 6 6 14.857143 $289.8600 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $47.3400 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.000000 $66.2100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $14.4000 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $57.8400 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $90.1600 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $27.6200 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 7 17.428571 $366.7000 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 1.000000 $75.1300 $75.1300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.093151 $10.7900 $115.8700
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 5 5 4.016667 $200.8400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 64 65 126.285714 $9471.4300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 23 23 45.500000 $3412.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 15 28.000000 $2100.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 44 44 83.785714 $6283.9300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 183 187 369.000000 $20479.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 53 54 105.571429 $5859.2100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 230 305 602.000000 $45150.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 79 101 199.071429 $14930.3600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.986301 $14.9000 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $257.0500 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.090411 $56.0600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.079452 $4.0900 $51.4400
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 4 4 23.714286 $1255.2000 $52.9300
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Subtotal (Total Children Is Unduplicated) 475 918 1756.191684 $118146.8900 $67.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 13 10.174429 $50872.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 4.205936 $210.3000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 8.071233 $1869.4500 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 264 294 316.973873 $15848.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 16 20 5.061648 $253.0700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 37 37 31.348337 $783.7100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 116 124 219.919045 $10995.9400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 13 15 23.955556 $1197.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 8 9.276190 $231.9100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 31 60.939681 $3046.9800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 7 8 11.666666 $583.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.083334 $127.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 47 67.607687 $3380.3900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 7 7 10.333333 $516.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 81 89 249.388090 $12469.3800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 9 10 11.772222 $588.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 7.500000 $187.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 59 62 369.233331 $18461.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 600 653 3904.266692 $195213.2500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 74 82 380.233332 $19011.6600 $50.0000
INTR -T1013 INTERPRETER 133 158 346.535716 $17326.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 777 994 5639.641286 $56396.3900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 14 61.569048 $4430.5100 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 54 56 273.133331 $19654.6600 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 35.571429 $2559.7200 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.164384 $18.8700 $114.8200
SENS -V5264 EARMOLD 2 2 0.493151 $8.9400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 62 449.776192 $32365.8800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 38.428570 $2765.3200 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 13.571428 $976.6100 $71.9600
TRAV -TRAVS Travel by mile 796 1016 5712.986524 $2542.2800 $0.4500
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Subtotal (Total Children Is Unduplicated) 936 3835 18278.881674 $474895.3100 $25.9800
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Total 4834 20186.730499 $593056.2600 $29.3800
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Number of Children (Unduplicated) With at Least One Authorization 1291