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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1871 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 16 16 8.880952 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 8.880952 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 8.311111 $466.2500 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 25 26 38.714286 $755.3200 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 11 11 11.000000 $260.3700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 9.000000 $132.1200 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 11 10.122222 $223.4000 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 14 11.377777 $81.9200 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 9 9 9.000000 $94.0500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 11.277777 $326.1500 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 9 10 10.000000 $450.8000 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 25 25 21.499999 $296.9100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 12 12.000000 $252.4800 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $61.0000 $61.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.800000 $81.5800 $45.3200
EXIT -EXIT EXIT ASSESSMENT 7 7 9.000000 $450.0000 $50.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 22 22 44.000000 $2442.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 40.000000 $3000.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 8.000000 $600.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 9 10 10.000000 $514.1000 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 8.288889 $426.1300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 3.561111 $183.0800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 14 15 10.827777 $556.6500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 8.866667 $455.8400 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 3.394444 $174.5100 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 4.844445 $249.0600 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 5.261112 $270.4800 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.505556 $25.9900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 28 29 22.311110 $1147.0100 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.377778 $19.4200 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 1.116667 $57.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 6.227778 $320.1700 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 1.811111 $93.1100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 26 28 20.216666 $1039.3400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 3.488889 $179.3600 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.288889 $57.8200 $44.8600
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
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Subtotal (Total Children Is Unduplicated) 204 363 384.492061 $16647.9100 $43.3000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 2.283333 $114.1700 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.811111 $56.2500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 4.000000 $277.4000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 115 152 86.591477 $4329.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 2 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 7.400000 $185.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 262 298 590.966657 $29548.2900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 125 202.166668 $10108.3400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.433333 $21.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 59 111.209520 $5560.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 114 121 203.564281 $10178.1900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 2.857143 $142.8600 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 9 9 36.876189 $1843.8100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 471 501 3642.828580 $182141.4300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 49 51 399.352381 $19967.6400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 42 220.142856 $15841.4900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 7.000000 $503.7200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 35 39 221.061901 $15907.6100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.428571 $318.6800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 69 73 545.953176 $39286.7900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 27.285714 $1963.4800 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 2 12.142857 $873.8000 $71.9600
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Subtotal (Total Children Is Unduplicated) 580 1492 6331.355748 $339452.2900 $53.6100
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Total 1871 6724.728761 $356100.2000 $52.9500
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Number of Children (Unduplicated) With at Least One Authorization 632