Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 4809 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 52 53 110.853968 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 52 53 110.853968 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 13 14.367123 $696.8000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 16.752382 $939.8100 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 14.857143 $289.8600 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 13.857143 $328.0000 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 13.857143 $203.4200 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 13.857143 $305.8300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 13.857143 $99.7700 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 2.466667 $25.7800 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 13.857143 $400.7500 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 13.857143 $624.6800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 13.857143 $191.3700 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 32.799218 $690.0900 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 11.587475 $1341.9500 $115.8100
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 182 186 367.000000 $20368.5000 $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 231 307 606.000000 $45450.0000 $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 7 7 8.000000 $411.2800 $51.4100
OCTH -97166 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 -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 4.505024 $68.0700 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.000000 $205.6400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.947554 $151.5300 $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 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 35.571429 $1882.7900 $52.9300
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Subtotal (Total Children Is Unduplicated) 460 930 1903.084969 $123545.5800 $64.9200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 12 16.702023 $83509.5000 $4999.9600
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 13.609393 $3152.2100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 262 294 331.564350 $16578.2200 $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 34.362623 $859.0700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 119 128 242.892857 $12144.6400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 11 11 21.650002 $1082.5100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 8 12.076190 $301.9100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 36 76.519050 $3825.9700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 4 4 6.100000 $305.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 6.166667 $154.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 46 77.738890 $3886.9500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 5 5 9.650000 $482.5000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 4.266667 $106.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 82 159.715875 $7985.8000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 9 16.083333 $804.1700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.100000 $102.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 70 74 485.714287 $24285.6900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 601 646 4383.285732 $219164.1700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 82 87 627.861906 $31393.1000 $50.0000
INTR -T1013 INTERPRETER 129 154 443.821429 $22191.0800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 780 988 6474.783356 $64747.8000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 20 116.038092 $8350.1100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 11.571429 $832.6800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 54 56 360.300002 $25927.1700 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 11.428572 $822.4000 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 2.806393 $322.2000 $114.8100
SENS -V5264 EARMOLD 3 3 2.663622 $48.2900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 64 430.747616 $30996.5700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 39.428572 $2837.2700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 23.142857 $1665.3600 $71.9600
TRAV -TRAVS Travel by mile 789 1012 6521.183355 $2901.9300 $0.4400
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Subtotal (Total Children Is Unduplicated) 885 3826 20973.036788 $572020.6300 $27.2700
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Total 4809 22986.975725 $695566.2100 $30.2600
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Number of Children (Unduplicated) With at Least One Authorization 986