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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5152 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 68 68 60.169841 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 68 68 60.169841 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 18 13.608677 $660.0300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 14 14 14.340182 $804.4800 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 9 9 27.933333 $442.4600 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 2.000000 $39.0200 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 9.933333 $219.2300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 12.933333 $113.9400 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 11.133333 $321.9800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $13.8100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 18.133333 $381.5200 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 2 0.933333 $56.9300 $61.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.276712 $32.0400 $115.8000
EXIT -EXIT COS Exit 70 74 54.266440 $2713.3100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 0.142857 $10.7200 $75.0200
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $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 9 12 24.000000 $1800.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 9 18.000000 $999.0000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 27 28 54.500000 $4087.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 41 41 82.000000 $6150.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 36 36 70.500000 $5287.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 4 4 7.500000 $562.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 222 229 454.505479 $25225.0600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 76 80 160.000000 $8880.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 256 313 623.505479 $46762.9100 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 60 73 146.000000 $10950.0000 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 12.714286 $688.7300 $54.1700
OCTH -97165 OT EVAL LOW COMPLEXITY 7 7 7.000000 $359.8700 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 5.000000 $257.0500 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 3.571429 $183.6100 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.526027 $7.9500 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 8.000000 $411.2800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 6.857143 $352.5200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.084932 $107.1800 $51.4100
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Subtotal (Total Children Is Unduplicated) 554 1029 1920.899641 $123694.0700 $64.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 13.182845 $65914.5000 $5000.0200
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 8.285714 $1919.1300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 242 270 301.309363 $15065.4700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 27 29 19.928085 $996.3900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 26 28 28.522147 $713.0500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 139 152 279.782536 $13989.1100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 6 6 13.166667 $658.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 5.600000 $140.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 69 71 120.833336 $6041.6800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 2.133333 $106.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 6.000000 $150.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 50 51 99.809525 $4990.4900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 4 4 5.333333 $266.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 1.766666 $44.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 68 72 109.079363 $5453.9600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 7 7 7.466667 $373.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 7.866667 $196.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 54 55 311.471434 $15573.5600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 689 725 4795.666682 $239783.3500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 58 62 400.552386 $20027.6100 $50.0000
INTR -T1013 INTERPRETER 137 197 331.623810 $16581.1900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 845 1047 6384.212728 $76610.5500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 40 198.128575 $14257.3200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 9.942857 $715.4900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 51 52 256.561908 $18462.1800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 9.142858 $657.9200 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.276712 $31.7700 $114.8000
SENS -V5264 EARMOLD 2 2 0.830137 $15.0500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 56 310.128574 $22316.8500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 8 8 34.285715 $2467.2000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.571429 $113.0800 $71.9600
TRAV -TRAVS Travel by mile 873 1074 6418.255587 $2856.1300 $0.4500
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Subtotal (Total Children Is Unduplicated) 1015 4055 20492.717639 $547488.8300 $26.7200
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Total 5152 22473.787121 $671182.9000 $29.8700
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Number of Children (Unduplicated) With at Least One Authorization 1374