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: 10-01-23 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 1642 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 5 5 8.799206 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 8.799206 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 20 20 19.172222 $1075.5600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 5 6 5.138889 $81.4000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 9.677778 $188.8100 $19.5100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 10.336509 $228.1300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.866667 $16.4500 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 4.000000 $115.6800 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 36 36 19.538886 $269.8300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.000000 $63.1200 $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
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 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 11 12 24.000000 $1800.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 11 12 12.000000 $616.9200 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 15 18 12.650000 $650.3400 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.377778 $70.8300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 6.727777 $345.8700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 7.000000 $359.8700 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 1.461111 $75.1200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 2.205556 $113.3900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 35 37 28.950001 $1488.3200 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 2 0.483333 $24.8500 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 4 1.783333 $91.6800 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.094444 $4.8500 $51.3900
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 36 39 22.855555 $1175.0000 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.300000 $66.8300 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 3.000000 $154.2300 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.477777 $75.9700 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 5 5 26.857143 $1380.7200 $51.4100
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Subtotal (Total Children Is Unduplicated) 197 268 253.954759 $12117.3100 $47.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 132 176 143.916678 $7195.8900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 3.750000 $93.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 216 247 588.914277 $29445.6700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 9.166666 $458.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 106 215.590475 $10779.5200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 37 63.838094 $3191.9000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.866667 $43.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 125 256.590475 $12829.5200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 3.233333 $161.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.400000 $35.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 422 447 3684.263504 $184213.1200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 56 57 459.147623 $22957.3700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 42 361.571430 $26018.6700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 14 14 121.000000 $8707.1700 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 7.000000 $503.7200 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.011111 $18.3300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 78 86 593.571433 $42713.3600 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 7 90.000000 $5184.0100 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 10.857143 $625.3700 $57.6000
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Subtotal (Total Children Is Unduplicated) 544 1369 6624.688909 $361112.8700 $54.5100
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Total 1642 6887.442874 $373230.1800 $54.1900
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Number of Children (Unduplicated) With at Least One Authorization 562