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 3475 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 43 43 35.745241 $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) 44 44 40.888098 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 32 33.084931 $1604.6200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 3.164384 $177.5200 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 7.285714 $115.4100 $15.8400
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.6800 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.2000 $7.2000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 3.000000 $63.1200 $21.0400
EXIT -EXIT EXIT ASSESSMENT 30 32 41.791194 $2089.5700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 29.000000 $1609.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 7 13.000000 $975.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.033333 $1.7600 $52.8800
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Subtotal (Total Children Is Unduplicated) 94 131 195.359556 $11153.3500 $57.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 9.110502 $45552.0000 $4999.9400
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 295 330 352.964484 $17648.2300 $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 65 66 113.719049 $5685.9600 $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 30 32 186.066668 $9303.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 38 41 289.933333 $14496.6900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 24.000000 $1200.0000 $50.0000
INTR -T1013 INTERPRETER 148 192 371.351585 $18567.5800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 840 1082 6779.449168 $67794.5000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 47.085714 $3388.2900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 4 4 15.485714 $1114.3500 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 0.566666 $40.7700 $71.9500
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.571429 $472.8800 $71.9600
TRAV -TRAVS Travel by mile 843 1092 6772.049170 $3013.5600 $0.4400
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Subtotal (Total Children Is Unduplicated) 946 3300 15710.482159 $222578.2600 $14.1700
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Total 3475 15946.729813 $233731.6100 $14.6600
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Number of Children (Unduplicated) With at Least One Authorization 998