Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1386 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 14 16 15.679364 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 16 15.679364 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 5.000000 $282.4500 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.7100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 9.000000 $211.4100 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $47.4000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 3.338889 $30.3200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 4.272222 $118.9000 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.066667 $90.5000 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 14 14 13.272222 $221.6500 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.066667 $46.2900 $22.4000
EXIT -EXIT EXIT ASSESSMENT 76 76 119.347164 $5967.3400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.057534 $4.3200 $75.0900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 2.057534 $114.2000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 24 25 16.471230 $914.1700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 18 2.471230 $185.3600 $75.0100
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.022222 $1.1300 $51.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 7.000000 $357.3500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 30 30 24.511567 $1251.3100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.1000 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 9.544443 $487.2400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 12.000000 $612.6000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 40 41 39.394900 $2011.1000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 9 9 8.488889 $378.1800 $44.5500
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Subtotal (Total Children Is Unduplicated) 201 283 308.383380 $15026.2700 $48.7300
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 5.285714 $378.5100 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 6 6 6.933333 $496.4900 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 80 105 83.387704 $4169.4100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 16 19 12.136114 $303.4100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 156 184 478.304761 $23915.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.300000 $57.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 67 129.190476 $6459.5300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 31 55.490476 $2774.5200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 72 76 141.871432 $7093.5900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.571429 $89.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 408 437 3302.352389 $165117.6500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 12.142857 $607.1500 $50.0000
INTR -T1013 INTERPRETER 4 5 7.428571 $371.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 40 322.333332 $23027.5000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 10.285714 $734.8100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 20 20 150.428573 $10746.6300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.428571 $316.3800 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.133333 $60.7800 $455.8900
SENS -V5264 EARMOLD 1 1 0.133333 $2.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 69 74 635.233334 $45381.0500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 2 22.285714 $1592.0900 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 8.571429 $612.3400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 6 62.000001 $4429.2800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 21.428572 $297.4300 $13.8800
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Subtotal (Total Children Is Unduplicated) 458 1087 5477.657162 $299034.3800 $54.5900
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Total 1386 5801.719906 $314060.6500 $54.1300
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Number of Children (Unduplicated) With at Least One Authorization 516