Summary Report for FSPSAs Initiated During the Report Period Center: 07
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: 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 1385 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 14 9.338887 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 9.338887 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 3.000000 $169.4700 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.544444 $30.4400 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 4.544444 $106.7500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 3.544444 $49.1600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 4.088888 $96.9000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 5.261111 $47.7700 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 5.261111 $146.4200 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 1.544444 $59.4100 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 3.088888 $262.0500 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 2.544444 $129.9400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 25 25 25.662698 $428.5700 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 7.816666 $175.0900 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $180.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 69 69 108.673973 $5433.6900 $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 18.468490 $1025.0200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 18 4.468490 $335.1600 $75.0100
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.250000 $12.7600 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.488889 $24.9600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.655556 $135.5700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 26 26 23.585463 $1204.0300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 2.450000 $125.0700 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 5 4.488889 $229.1600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 12.236508 $624.6700 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 6.000000 $306.3000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 35 36 23.301901 $1189.5600 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $204.2000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 3 2.133333 $108.9100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 11.307936 $503.7700 $44.5500
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Subtotal (Total Children Is Unduplicated) 201 310 316.526078 $14765.4100 $46.6500
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 7.452381 $533.6700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 7.866667 $1809.3400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 73 104 89.824610 $4491.2600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 14 17 9.036114 $225.9100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 158 175 441.291666 $22064.5800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.833333 $141.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 4.866667 $121.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 83 153.952382 $7697.6300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 41 82.052380 $4102.6200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 77 167.766670 $8388.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 4 10.399999 $260.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.400000 $70.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 388 413 3357.697316 $167884.8600 $50.0000
INTR -T1013 INTERPRETER 2 3 4.285714 $214.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 31 251.142855 $17941.6500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.000000 $71.4400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 25 26 273.999999 $19574.5700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.714286 $622.5500 $71.4400
SENS -V5264 EARMOLD 1 1 5.866667 $105.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 49 55 443.285709 $31668.3200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 21.428571 $1530.8600 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 2 10.000000 $714.4000 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 6 40.366667 $2883.8000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 55.285715 $767.3700 $13.8800
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Subtotal (Total Children Is Unduplicated) 437 1061 5451.816368 $293886.3700 $53.9100
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Total 1385 5777.681333 $308651.7900 $53.4200
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Number of Children (Unduplicated) With at Least One Authorization 495