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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1913 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 14 14 14.676192 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 14 14 14.676192 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 14 14 13.500000 $833.0900 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 6 6 7.938888 $120.5900 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 17 18 11.544445 $247.7500 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $26.0400 $26.0400
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 1.722222 $41.8200 $24.2800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 9.738096 $309.7700 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 36 36 19.394446 $294.6000 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 32.801587 $759.0300 $23.1400
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 9.142857 $547.8400 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 7.142857 $578.4300 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $161.9600 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 11 13 12.111111 $703.7800 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 19 20 12.250002 $711.8600 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 6.000000 $348.6600 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 2.000000 $116.2200 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 21 21 17.466667 $1014.9900 $58.1100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 1.322222 $76.8300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 6.477778 $376.4200 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 14 15 6.488887 $377.0600 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 2.616667 $152.0600 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.250000 $14.5300 $58.1100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 2 1.322222 $76.8300 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 34 35 25.572223 $1486.0100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 6.355556 $369.3200 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 51 53 34.100000 $1981.5500 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 1.422222 $82.6400 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.477778 $27.7700 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.311111 $76.1900 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $116.2200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 12.285715 $713.9200 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 239 304 272.755559 $13034.3200 $47.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 11.000000 $2547.8200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 135 159 128.903980 $6445.2500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 6 4.750000 $237.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 5.133333 $128.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 245 275 585.704765 $29285.2500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 5.533334 $276.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 124 131 249.199999 $12460.0000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 3.566667 $178.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.833333 $20.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 47 91.500000 $4575.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 140 162 298.566667 $14928.3400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 1.900000 $95.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.366667 $34.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 537 572 4500.123792 $243006.8000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 24 25 189.611109 $10239.0000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 56 444.285715 $36129.3000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 30 32 190.209527 $15467.8400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.285714 $348.5100 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 1 3.571429 $64.7500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 91 98 598.780954 $48692.9200 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 8 97.695238 $6361.9100 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 37.142857 $2418.7400 $65.1200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 621 1595 7456.665080 $439401.4900 $58.9300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1913 7744.096831 $452435.8100 $58.4200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 649