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: 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 1790 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 24 24 27.442064 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 27.442064 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 7.000000 $431.9700 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 11 11 5.455556 $82.8700 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 16 16 12.438888 $266.9400 $21.4600
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 3.144445 $76.3500 $24.2800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 4.487518 $142.7400 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 24 24 12.527778 $190.3000 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 20 20 15.855555 $366.9000 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 2.566667 $116.3200 $45.3200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 5.142857 $308.1600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 3.142857 $254.5100 $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 6 7 7.000000 $406.7700 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 29 31 22.966664 $1334.5800 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.472222 $27.4400 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.111111 $64.5700 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 16 12.949999 $752.5200 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.433333 $25.1800 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 3.916666 $227.5900 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 12 14 7.349999 $427.1000 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 3.027777 $175.9400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 35 36 24.488889 $1423.0500 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 8 12.888889 $748.9700 $58.1100
SPCH -92522GT 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 35 35 21.827776 $1268.4000 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.411111 $23.8900 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.277778 $16.1400 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.466667 $27.1200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 46.428572 $2697.9700 $58.1100
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Subtotal (Total Children Is Unduplicated) 221 271 243.779574 $12278.6900 $50.3700
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.822222 $126.3700 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 12.566667 $2910.7000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 137 162 129.658743 $6482.9900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 7 7 5.750000 $287.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.750000 $18.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 230 261 582.141274 $29107.0900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 5.266667 $263.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 117 126 238.842857 $11942.1500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 3.500000 $175.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 46 103.295239 $5164.7700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 130 210.155555 $10507.7800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 3.733334 $186.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 526 558 3981.842889 $215019.5900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 24 179.133335 $9673.2000 $54.0000
INTR -T1013 INTERPRETER 2 2 11.857143 $592.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 49 368.638096 $29977.6700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 2 2 8.285714 $539.5700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 25 29 240.800002 $19581.8700 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.857143 $720.2600 $81.3200
SENS -V5261 BEHIND EAR DIGITAL BINAURAL HEARING 1 1 2.566667 $2517.2700 $980.7500
SENS -V5264 EARMOLD 1 1 1.822222 $33.0400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 70 72 565.285718 $45969.0500 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 8 46.000000 $2995.5300 $65.1200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 1 1 3.000000 $195.3600 $65.1200
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Subtotal (Total Children Is Unduplicated) 618 1495 6715.571487 $394988.3500 $58.8200
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Total 1790 6986.793125 $407267.0400 $58.2900
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Number of Children (Unduplicated) With at Least One Authorization 642