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: 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 5438 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 48 48 77.678573 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.142857 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 49 49 82.821430 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 32 34 35.084931 $1701.6200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 10.818265 $606.9000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 8 8 22.819047 $361.4500 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 3.000000 $58.5300 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $94.6800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 5.000000 $73.4000 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 13.533333 $298.6800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 14.533333 $104.6400 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 13.533333 $391.3800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 4 4.000000 $180.3200 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.000000 $41.4300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 11 21.533333 $453.0600 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 3.285714 $285.6600 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 1.000000 $75.1300 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.164384 $7.4500 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 11.428571 $1323.5500 $115.8100
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 40 78.500000 $5887.5000 $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 218 221 435.142857 $24150.4300 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 93 98 189.566667 $10520.9500 $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
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
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
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.8200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.224658 $62.9600 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $257.0500 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.104110 $5.3500 $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 23.057143 $1220.4100 $52.9300
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Subtotal (Total Children Is Unduplicated) 539 1079 2042.127069 $131819.4700 $64.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 31 28.579603 $142897.0000 $4999.9600
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 5.000000 $1158.1000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 300 336 358.714484 $17935.7300 $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 54 57 77.482387 $1937.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 159 167 282.061114 $14103.0700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 13 14 37.383333 $1869.1700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 6.988889 $174.7200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 57 101.188887 $5059.4400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 7 7 13.085713 $654.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 7.288889 $182.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 66 67 113.730160 $5686.5200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 4 4 8.433333 $421.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 4 4.588889 $114.7200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 95 96 163.188886 $8159.4300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 6 7 14.733332 $736.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 23.166667 $579.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 62 65 400.709525 $20035.4700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 697 746 5084.809498 $254240.5300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 50 51 342.885714 $17144.3200 $50.0000
INTR -T1013 INTERPRETER 165 217 401.887299 $20094.3700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 842 1086 6802.020596 $68020.2200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 34 236.390474 $17010.6600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 10.285714 $740.1600 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 1.133333 $81.5500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 57 57 339.704758 $24445.1600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 11.714286 $842.9600 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 4 4 26.114287 $1879.1800 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 7.428571 $534.5600 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.120548 $13.8300 $114.7600
SENS -V5264 EARMOLD 1 1 0.328767 $5.9600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 58 382.314282 $27511.3500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 34.980952 $2517.2300 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.933333 $139.1200 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 3.714286 $51.8500 $13.9600
TRAV -TRAVS Travel by mile 846 1097 6805.049169 $3028.2400 $0.4400
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Subtotal (Total Children Is Unduplicated) 966 4310 22140.678316 $660082.5600 $29.8100
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Total 5438 24265.626815 $791902.0300 $32.6300
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Number of Children (Unduplicated) With at Least One Authorization 1100