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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5003 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 66 68 75.338093 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.233333 $8.6800 $37.1900
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Subtotal (Total Children Is Unduplicated) 67 69 75.571426 $8.6800 $0.1100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 26 30.352577 $1472.1000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 3.082192 $172.9100 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 5.000000 $97.5500 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.000000 $71.0100 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 4.000000 $58.7200 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.000000 $66.2100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.000000 $21.6000 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.000000 $86.7600 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 3.000000 $135.2400 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.000000 $41.4300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 3.805479 $80.0700 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.082192 $94.3700 $45.3200
EXIT -EXIT EXIT ASSESSMENT 37 40 46.576908 $2328.8600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 8 13.000000 $975.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 15 29.500000 $2212.5000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 13 13 25.500000 $1415.2500 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 40 41 81.000000 $6075.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 23 24 48.000000 $3600.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 25 49.000000 $3675.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 9 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 42 43 84.000000 $6300.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 16 17 34.000000 $2550.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 217 220 433.642857 $24067.1800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 94 99 191.566667 $10631.9500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 230 287 558.220482 $41866.5500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 79 96 190.000000 $14250.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.805479 $12.1700 $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 2 2 3.214286 $165.2500 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 4 5 50.857143 $2691.8700 $52.9300
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Subtotal (Total Children Is Unduplicated) 543 1039 1971.206262 $129749.7200 $65.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 23 30.448989 $152244.5000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 24.991389 $5788.5100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 293 331 345.714484 $17285.7300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 11 13 1.538358 $76.9000 $49.9900
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 50 52 45.420484 $1135.5100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 115 123 220.650004 $11032.5200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 14 14 24.283334 $1214.1700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 6 6.000001 $150.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 37 66.580952 $3329.0500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 4.366667 $218.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.433333 $35.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 54 99.250001 $4962.5100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 8 8 12.400000 $620.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.066667 $51.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 80 86 142.455563 $7122.8200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 7 7 8.833333 $441.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.200001 $130.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 55 57 339.838095 $16991.9100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 599 655 4192.661917 $209633.1100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 60 63 392.042855 $19602.1600 $50.0000
INTR -T1013 INTERPRETER 167 211 421.078572 $21053.9300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 765 981 5970.500020 $59705.0100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 24 138.371430 $9957.2100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 5.571429 $400.9200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 56 60 402.519048 $28965.2600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 25.428571 $1829.8400 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 5.428571 $390.6400 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.134247 $15.4100 $114.7700
SENS -V5264 EARMOLD 3 3 2.567124 $46.5400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 58 384.814284 $27691.2500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 50.019047 $3599.3700 $71.9600
TRAV -TRAVS Travel by mile 776 997 6001.019068 $2670.4600 $0.4500
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Subtotal (Total Children Is Unduplicated) 968 3895 19373.627838 $608392.7200 $31.4000
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Total 5003 21420.405526 $738151.1200 $34.4600
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Number of Children (Unduplicated) With at Least One Authorization 1319