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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1919 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 13 13 18.780951 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 18.780951 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 13 13 9.072223 $508.9600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 13 14 12.555555 $198.8800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 17 18 13.566667 $264.6900 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.000000 $44.0400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 7.350794 $162.2300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 3 2.266667 $19.9700 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 12.866667 $372.1100 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 28 29 14.761110 $203.8500 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 27.000000 $568.0800 $21.0400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 14.000000 $777.0000 $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 9 10 20.000000 $1500.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 11 11 12.000000 $616.9200 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 19 20 13.555556 $696.8900 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 4.133333 $212.4900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 12 7.427779 $381.8700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.8200 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.344444 $17.7100 $51.4000
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 6.000000 $308.4600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 2.988889 $153.6600 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.338889 $17.4200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 3.894444 $200.2100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 43 44 29.711111 $1527.4500 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.161111 $59.6900 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 2 0.477778 $24.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 2.616667 $134.5200 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 37 41 26.783335 $1376.9400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $205.6400 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 2 2.000000 $102.8200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.583334 $81.4000 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 12.857143 $660.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 228 303 279.313496 $12028.5000 $43.0600
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 2.133333 $147.9400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 11 11 11.711111 $2712.5300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 133 176 131.312114 $6565.6800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 3.583333 $89.5800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 261 297 689.047619 $34452.3800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.500000 $37.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 140 148 283.142856 $14157.1300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.966667 $24.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 38 67.599999 $3380.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 138 153 281.023815 $14051.2200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.000000 $100.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 14 14 114.995238 $5749.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 489 527 3703.375397 $185168.8000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 57 60 398.230953 $19911.5600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 46 388.714287 $27971.8700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 18 18 141.714287 $10197.7600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 6.142857 $442.0400 $71.9600
SENS -V5264 EARMOLD 1 1 1.422222 $25.7800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 92 675.890475 $48637.0700 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 6 49.571430 $2855.3100 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 12.857143 $740.5700 $57.6000
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Subtotal (Total Children Is Unduplicated) 606 1603 6972.935136 $377593.6500 $54.1500
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Total 1919 7271.029583 $389622.1500 $53.5900
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Number of Children (Unduplicated) With at Least One Authorization 640