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: 01-01-23 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 1761 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 8.834127 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 8.834127 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 8 8 6.750000 $378.6800 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 4 4 2.811111 $44.5300 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 5.000000 $97.5500 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.000000 $71.0100 $23.6700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.111111 $2.4500 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.555556 $4.0000 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.033333 $0.3500 $10.4400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $57.8400 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 37 37 22.238889 $307.1200 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.055556 $43.2500 $21.0400
EXIT -EXIT EXIT ASSESSMENT 4 4 4.000000 $200.0000 $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 8 8 7.361111 $378.4300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 18 18 12.850000 $660.6200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.316667 $16.2800 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 3.227778 $165.9400 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.366667 $18.8500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 12 13 12.355556 $635.2000 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 14 16 11.933335 $613.5000 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.100000 $5.1400 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.644445 $33.1300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 5.238889 $269.3300 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 27 28 20.083333 $1032.4800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.338889 $68.8300 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 2.161111 $111.1000 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.500000 $77.1200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 31 32 23.683332 $1217.5500 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 7 7.000000 $359.8700 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.411111 $72.5400 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.105556 $5.4300 $51.4300
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 3.316667 $148.7900 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 4 17.923810 $948.7100 $52.9300
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Subtotal (Total Children Is Unduplicated) 203 251 219.473813 $10497.4500 $47.8300
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.533333 $36.9800 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.177778 $736.0400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 128 173 119.254761 $5962.8300 $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 11.775001 $294.3800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 255 280 600.582322 $30029.1200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 2 5.333334 $266.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 120 124 210.457147 $10522.8800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.733333 $68.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 58 61 110.414286 $5520.7200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.533333 $13.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 140 229.466666 $11473.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.466667 $61.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 21 21 152.528570 $7626.4500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 392 414 2845.590473 $142279.5900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 92 95 873.599998 $43680.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 2.714285 $27.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 35 247.066669 $17778.9400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 34 36 199.866665 $14382.4400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 13.714285 $986.8800 $71.9600
SENS -V5264 EARMOLD 1 1 0.888889 $16.1200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 80 85 659.000004 $47421.6300 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 9 55.571426 $3200.9200 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 8.714286 $627.0800 $71.9600
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Subtotal (Total Children Is Unduplicated) 589 1494 6356.983511 $343063.4600 $53.9700
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Total 1761 6585.291451 $353560.9200 $53.6900
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Number of Children (Unduplicated) With at Least One Authorization 621