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 1579 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 4 4 5.000000 $278.5500 $55.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 2.000000 $47.0000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.205556 $2.0100 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.205556 $5.9000 $28.7300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.205556 $16.5300 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 9.285714 $193.9800 $20.8900
EXIT -EXIT EXIT ASSESSMENT 73 73 135.970451 $6798.5200 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 8.032876 $445.8200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.261111 $13.3300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 4.133333 $211.0100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.222222 $11.3400 $51.0400
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 1.711111 $87.3500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.411111 $20.9900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 3.866667 $197.4000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 2.027778 $90.3400 $44.5500
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Subtotal (Total Children Is Unduplicated) 104 116 179.539042 $8771.1100 $48.8500
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 3.000000 $206.5800 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 6.000000 $1380.0000 $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 204 219 1569.796427 $78489.8300 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 3.714286 $265.3500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 12.285715 $877.6900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 9 60.857142 $4347.6400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.857143 $418.4300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 26.571428 $1898.2700 $71.4400
TRAV -TRAVS Travel by mile 1 1 13.142857 $5.8500 $0.4500
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Subtotal (Total Children Is Unduplicated) 582 1440 3900.648186 $197153.7200 $50.5400
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Total 1579 4115.292784 $205924.8400 $50.0400
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Number of Children (Unduplicated) With at Least One Authorization 635