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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1746 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 15 16 15.219050 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 16 15.219050 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 7.000000 $389.9700 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 3.911111 $91.9100 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 8 7.911111 $185.9100 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 2.827778 $41.2300 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 4.911111 $115.4100 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 5.655554 $55.3700 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 3.000000 $29.3700 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 9 9 6.261110 $179.8200 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 4.911111 $219.8200 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 21 18.261110 $250.3600 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 14 14 24.678571 $515.5400 $20.8900
EXIT -EXIT EXIT ASSESSMENT 24 24 34.122832 $1706.1400 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 33 64.022222 $3553.2300 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 28 56.000000 $4200.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 7 7.000000 $357.3500 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 11.428571 $583.4300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 0.827779 $42.2600 $51.0600
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 33 36 27.383332 $1397.9100 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.166667 $8.5100 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 5.500000 $280.7800 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 21 17.116666 $873.8000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 10 11 12.894444 $658.2600 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.355556 $18.1500 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 30 31 19.805555 $1011.0700 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.372222 $70.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 11 9.138889 $407.1400 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.472222 $21.0400 $44.5500
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Subtotal (Total Children Is Unduplicated) 212 324 389.935524 $19496.8800 $50.0000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 12 12 43.712697 $3010.0600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 5.472222 $1258.6100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 124 168 112.542866 $5627.1900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 7.661112 $191.5300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 240 277 592.100203 $29605.0500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.466667 $73.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 3.800000 $95.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 115 122 279.366671 $13968.3600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 6.566666 $164.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 49 104.138892 $5206.9600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 121 229.247625 $11462.4100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 3.142857 $157.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 5.166667 $129.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 469 491 3969.682537 $198484.1600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 38 237.714289 $16982.3200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 33.285715 $2377.9300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.571429 $40.8200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 6.285714 $449.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 24 25 208.535716 $14897.8100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 18.857143 $1347.1500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 61 430.823809 $30778.0800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.571428 $826.6600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.285714 $449.0500 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 5 7 32.714285 $454.0800 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 10.571429 $146.7300 $13.8800
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Subtotal (Total Children Is Unduplicated) 553 1406 6362.284353 $338232.8100 $53.1600
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Total 1746 6767.438927 $357729.6900 $52.8600
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Number of Children (Unduplicated) With at Least One Authorization 614