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: 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 1547 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 24 31.986510 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 23 24 31.986510 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $111.4200 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.911111 $44.9100 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.911111 $44.9100 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.5800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.911111 $44.9100 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 1.988888 $19.4700 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $9.7900 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 2.594444 $74.5100 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.911111 $85.5400 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 5 5 2.594444 $35.5700 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 12.196825 $254.7900 $20.8900
EXIT -EXIT EXIT ASSESSMENT 42 42 63.320452 $3166.0300 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $444.0000 $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 1 1 0.455556 $23.2600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 7 6.100000 $311.4100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.288889 $14.7500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 2 0.811112 $41.4100 $51.0600
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.200000 $10.2100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 4.388889 $224.0500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.194444 $9.9200 $51.0400
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 2.483333 $110.6300 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 68 103 122.261720 $5447.1200 $44.5500
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 9.142857 $457.1500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 3.000000 $206.5800 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 191 267 184.184500 $9209.3000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 3.066667 $153.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 14 15 12.487482 $312.1900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 361 407 903.027585 $45151.4100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.466667 $73.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 3.800000 $95.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 178 190 418.934529 $20946.7600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 12.700000 $317.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 80 174.105559 $8705.3000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.700000 $85.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.433333 $35.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 192 206 395.261914 $19763.1400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 3.142857 $157.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.733334 $168.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 193 206 1769.781343 $88489.1100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 6.142857 $307.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 28.142857 $2010.5300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 6.571429 $469.4600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 44.857141 $3204.6100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 13 102.340476 $7311.2100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.714286 $408.2300 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 12.428571 $172.5100 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 566 1420 4111.166244 $208440.0900 $50.7000
-------------------------------------------------------------------------------------------------------------------------------------
Total 1547 4265.414474 $213887.2100 $50.1400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 619