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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1639 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 23 23 22.933331 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 23 23 22.933331 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 8.166667 $503.9700 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 9 9 5.638889 $85.6500 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 15 15 13.940476 $299.1600 $21.4600
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 1.866667 $45.3200 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.561111 $4.4400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 9 9 7.793837 $247.9200 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 23 23 15.416664 $234.1700 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 17 17 13.766667 $318.5600 $23.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.533333 $24.1700 $45.3200
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.011111 $0.6700 $59.8600
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.011111 $0.9000 $80.9000
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 6 5.066667 $294.4300 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 22 22 13.950000 $810.6300 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 3 3 0.888888 $51.6500 $58.1000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.222222 $129.1300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 6.788889 $394.5000 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 7.294444 $423.8800 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 12 12 4.255557 $247.3000 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 2.744444 $159.4800 $58.1100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.488889 $28.4100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 38 38 21.277781 $1236.4700 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.261111 $15.1700 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 7 7.911111 $459.7100 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 27 27 17.883333 $1039.2000 $58.1100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.416667 $24.2100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 4.050000 $235.3500 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 8 8 42.857144 $2490.4300 $58.1100
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Subtotal (Total Children Is Unduplicated) 205 250 208.063680 $9921.1100 $47.6800
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.200000 $13.8700 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 8.533333 $1976.4800 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 114 147 136.905165 $6845.2900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 9 9 9.000000 $450.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 12 13 11.750000 $293.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 209 235 519.929366 $25996.4800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 5 11.066667 $553.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 107 198.014285 $9900.7200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 4 6.900000 $345.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 3 1.866667 $46.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 43 77.109523 $3855.4800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 117 209.061905 $10453.1000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 3.466666 $173.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 468 488 3510.071423 $189543.8000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 33 34 230.476186 $12445.7000 $54.0000
INTR -T1013 INTERPRETER 1 1 8.428571 $421.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 37 358.428571 $29147.4000 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 7.142857 $580.8600 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 5 6 33.571429 $2186.1800 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 8.285714 $539.5600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 27 27 199.857147 $16252.3500 $81.3200
SENS -V5261 BEHIND EAR DIGITAL BINAURAL HEARING 1 1 0.533333 $523.0300 $980.6800
SENS -V5264 EARMOLD 1 1 0.200000 $3.6300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 68 473.142856 $38475.9600 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 52.714285 $3432.7600 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 0.285714 $18.6000 $65.1200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 1 1 10.571429 $688.4100 $65.1200
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Subtotal (Total Children Is Unduplicated) 536 1366 6087.513092 $355163.1700 $58.3400
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Total 1639 6318.510103 $365084.2800 $57.7800
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Number of Children (Unduplicated) With at Least One Authorization 559