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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1834 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 21 21 12.784921 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 12.784921 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 6 6 12.714286 $708.3100 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 10 11 16.908730 $397.3500 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 11 11 11.000000 $258.5000 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 8 8 8.000000 $116.6400 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 8 8.000000 $188.0000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 13 9.066667 $88.7600 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 8 8 8.000000 $78.3200 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 14 14 10.066667 $289.1200 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 8 8 8.000000 $358.0800 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 32 32 29.466667 $403.9900 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 16 16 16.000000 $334.2400 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 20 20 33.750000 $1687.5000 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 18 18 36.000000 $1998.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 16 16 32.000000 $2400.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 6 5.077778 $259.2200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 2.394444 $122.2300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 1.800000 $91.8900 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 26 26 29.193989 $1490.3600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 4.200000 $214.4100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.127778 $159.6700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 12 5.255555 $268.2900 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 2.855554 $145.7700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 2.922222 $149.1800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 38 39 30.516668 $1557.8800 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 3 3.000000 $153.1500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 11 13 9.755555 $434.6100 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 4 23.571428 $1239.1500 $52.5700
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Subtotal (Total Children Is Unduplicated) 204 329 372.643988 $16138.9300 $43.3100
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 8.714286 $435.7200 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 7.714286 $531.2100 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 4.788889 $329.7600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 5.222222 $1201.1100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 151 195 118.873573 $5943.7800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 7.488095 $187.2000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 259 292 629.597610 $31479.8700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.800000 $140.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 2.066666 $51.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 132 135 223.669045 $11183.4400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 41 66.219046 $3310.9500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 127 231.045230 $11552.2300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.400000 $60.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 30.466666 $1523.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 466 492 3704.569816 $185228.5100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 18 18 69.428572 $3471.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 42 330.342857 $23599.7000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 6.714286 $479.6700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 18 19 104.214284 $7445.0800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.142857 $10.2100 $71.4600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.688889 $314.1400 $456.0100
SENS -V5264 EARMOLD 1 1 1.377778 $24.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 76 522.590469 $37333.8900 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 3.142858 $224.5200 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 6 6 57.428570 $797.1100 $13.8800
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Subtotal (Total Children Is Unduplicated) 565 1484 6144.706850 $327009.3100 $53.2200
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Total 1834 6530.135759 $343148.2400 $52.5500
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Number of Children (Unduplicated) With at Least One Authorization 611