Summary Report for FSPSAs Ending During the Report Period Center: 52
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 722 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 2 2 1.100000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.100000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.633333 $23.9800 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.633333 $11.7600 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.633333 $47.2400 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.633333 $34.3600 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.134247 $6.0800 $45.3000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.134247 $15.5400 $115.7700
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 5.000000 $257.0500 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.866667 $198.7900 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SCREEN-T1023 SCREENING 31 31 32.733333 $1636.6700 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 10.000000 $514.1000 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 7 6.866667 $353.0200 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 9.285714 $491.4900 $52.9300
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Subtotal (Total Children Is Unduplicated) 58 76 86.554207 $4205.5800 $48.5900
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.633333 $81.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 143 307.183337 $15359.1900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 77 157.199999 $7860.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 56 135.866666 $6793.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 69 73 163.266667 $8163.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 5.900001 $147.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.966667 $49.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 0.600000 $30.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 161 167 922.723810 $46136.1600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 2 3.666666 $183.3300 $50.0000
INTR -T1013 INTERPRETER 3 3 20.285714 $1014.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 21 53.966666 $3883.4300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 5 28.552382 $1644.6200 $57.6000
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 3.200000 $184.3200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 23 23 117.580952 $8461.1300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 7.400001 $532.5100 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 6 28.164285 $1621.1400 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 2.066667 $148.7200 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 1 0.544444 $9.8700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 45 47 217.790476 $15672.2000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 7.542857 $542.7900 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 2 5.333333 $383.7800 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 2.000000 $27.9200 $13.9600
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Subtotal (Total Children Is Unduplicated) 235 644 2196.434923 $119389.6100 $54.3600
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Total 722 2284.089130 $123595.1900 $54.1100
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Number of Children (Unduplicated) With at Least One Authorization 243