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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1909 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 22 22 11.062699 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 22 11.062699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 16 16 15.083333 $846.1700 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 19 19 19.911111 $388.4700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $94.6800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.000000 $66.2100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 4.350000 $31.3200 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 3.000000 $31.3500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 14 14 11.350000 $328.2400 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 3.000000 $135.2400 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 35 35 32.350000 $446.7500 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.000000 $42.0800 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
EXIT -EXIT EXIT ASSESSMENT 7 7 8.000000 $400.0000 $50.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 18.000000 $999.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 16.000000 $1200.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 7.000000 $359.8700 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 0.316667 $16.2800 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 21 21 15.199999 $781.4300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 5 4.727778 $243.0600 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 3.833333 $197.0700 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 9 9.000000 $462.6900 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 11 12 7.827778 $402.4300 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.400000 $20.5600 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 4 0.661111 $33.9900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 14 3.300000 $169.6500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 38 38 25.881746 $1330.5800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.188889 $9.7100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 1.983333 $101.9600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 39 41 27.944445 $1436.6300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 4 4.000000 $205.6400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.088889 $55.9800 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.394444 $71.6900 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.305556 $13.7100 $44.8700
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 3 20.000000 $1058.6000 $52.9300
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Subtotal (Total Children Is Unduplicated) 227 315 283.098412 $12424.3500 $43.8900
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 3.194444 $221.5300 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 13.000000 $3011.0600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 122 169 112.549207 $5627.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 3.541667 $88.5400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 269 303 627.827559 $31391.3900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 121 129 209.052385 $10452.6400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 59 140.766666 $7038.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.466667 $61.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 127 140 220.866668 $11043.3400 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 11 11 51.042857 $2552.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 455 478 3468.995243 $173449.8400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 75 78 567.395238 $28369.7700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 2.714285 $27.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 42 273.433335 $19676.2500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.714286 $51.4000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 33 36 239.161905 $17210.0900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.571429 $113.0800 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 2 2 5.388889 $97.7000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 101 661.571427 $47606.6600 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 10.571428 $608.9100 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 4.142857 $298.1200 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.000000 $287.8400 $71.9600
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Subtotal (Total Children Is Unduplicated) 606 1572 6628.968442 $360372.8000 $54.3600
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Total 1909 6923.129553 $372797.1500 $53.8500
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Number of Children (Unduplicated) With at Least One Authorization 643