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: 10-01-22 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 1571 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 18 18 20.233332 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 20.233332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 12.000000 $673.2000 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 8 8 8.000000 $156.0800 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.000000 $71.0100 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.6800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $22.0700 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 2.272222 $16.3600 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.911111 $55.2700 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 25 25 56.911111 $785.9400 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.000000 $42.0800 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.244444 $56.4000 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
EXIT -EXIT EXIT ASSESSMENT 5 5 6.000000 $300.0000 $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 8 9 9.000000 $462.6900 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 9.055555 $465.5400 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 4.816667 $247.6300 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 7.000000 $359.8700 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 10 10 6.188888 $318.1700 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 4.300001 $221.0700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 33 36 25.288888 $1300.1000 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 4 1.155556 $59.4100 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 1.211111 $62.2600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 20 20 14.622223 $751.7300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.733334 $32.9000 $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) 176 241 290.711111 $13684.2500 $47.0700
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.211111 $14.6400 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.000000 $138.7000 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 106 135 98.010924 $4900.6100 $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 4 4 4.666667 $116.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 239 264 572.847620 $28642.3900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 112 234.338095 $11716.9100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.200000 $5.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 50 108.552381 $5427.6200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.600000 $15.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 93 100 185.085709 $9254.2600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 3.714286 $185.7200 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 15 15 67.166665 $3358.3300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.928571 $46.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 383 403 3138.502395 $156925.0500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 83 84 763.252387 $38162.5900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 29 213.714285 $15378.8700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 26 31 195.319047 $14055.1500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 12.714286 $914.9100 $71.9600
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 70 550.248417 $39595.8500 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.857143 $164.5700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 10.428571 $750.4400 $71.9600
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Subtotal (Total Children Is Unduplicated) 551 1312 6167.358560 $329837.8100 $53.4800
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Total 1571 6478.303003 $343522.0600 $53.0300
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Number of Children (Unduplicated) With at Least One Authorization 593