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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2967 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 35.105556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 23 23 35.105556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 15 15 16.000000 $891.3600 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 10 10 11.000000 $258.5000 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 17 17 20.035616 $470.8400 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 15 15 17.211111 $250.9400 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 14 14 17.000000 $399.5000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 20 20 12.627779 $123.6300 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 10 10 11.000000 $107.6900 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 29 29 23.222224 $666.9500 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 13 13 16.000000 $716.1600 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 14 14 17.000000 $1442.2800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 13 13 15.000000 $766.0500 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 40 40 31.966668 $438.2700 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 44 44 68.142857 $1423.5000 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 15.351838 $690.8400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.211111 $24.2800 $114.9900
EXIT -EXIT EXIT ASSESSMENT 73 73 135.970451 $6798.5200 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 42 42 74.126331 $4114.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 36 36 64.104109 $4807.8000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 5.000000 $255.2500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 3.261111 $166.4800 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.005556 $0.2900 $51.4600
OCTH -97167 OT EVAL HIGH COMPLEXITY 53 54 41.816665 $2134.7300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 1.222222 $62.3900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 4.627779 $236.2500 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 10.714286 $546.9700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 29 29 20.383334 $1040.5700 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 3.411111 $174.1400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 1.905555 $97.2800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 63 64 45.757145 $2335.9100 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.233333 $62.9600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 6 6 5.261111 $268.5800 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 27 27 18.238889 $812.5400 $44.5500
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Subtotal (Total Children Is Unduplicated) 362 643 758.808192 $34631.5300 $45.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.027778 $139.0000 $5003.9600
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.266667 $63.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.188889 $159.4500 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.266667 $87.2300 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 22 22 43.409524 $2989.1900 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 17.566666 $4040.3200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 170 242 176.691047 $8834.6300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 20 20 16.987483 $424.6900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 385 427 992.794640 $49639.7100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.466667 $73.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 6.500000 $162.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 179 189 369.283339 $18464.1900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 6.300000 $315.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 73 77 160.714290 $8035.7300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.633333 $65.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 213 225 459.457151 $22972.8900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 3.428571 $171.4300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.166667 $54.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 750 792 6140.942474 $307047.0900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 3.571429 $178.5700 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 71 75 560.190481 $40019.9900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 5.714286 $408.2300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 3 3 14.571429 $1040.9800 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.000000 $214.3200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 35 38 243.280952 $17379.9900 $71.4400
SENS -V5264 EARMOLD 1 1 1.266667 $22.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 124 135 988.428578 $70613.3200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 16.285715 $1163.4400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 10.857143 $775.6300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 9 9 66.571427 $4755.8800 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 21.571429 $299.4100 $13.8800
TRAV -TRAVS Travel by mile 1 1 13.142857 $5.8500 $0.4500
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Subtotal (Total Children Is Unduplicated) 850 2301 10355.544246 $560668.1000 $54.1400
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Total 2967 11149.457994 $595299.6300 $53.3900
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Number of Children (Unduplicated) With at Least One Authorization 946