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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1749 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 18.561113 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 18.561113 $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 1.377778 $32.3800 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.377778 $102.8800 $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 1.377778 $32.3800 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 1.094444 $10.7100 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $9.7900 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 3.161111 $90.7900 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.377778 $61.6700 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 8 8 5.094444 $69.8400 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.377778 $28.7800 $20.8900
EXIT -EXIT EXIT ASSESSMENT 43 43 64.726191 $3236.3200 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.500000 $25.5300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.450000 $22.9700 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 2.000000 $102.1000 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.283333 $14.4600 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 5.455556 $278.5100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 4.000000 $178.2000 $44.5500
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Subtotal (Total Children Is Unduplicated) 80 109 126.653969 $5947.7100 $46.9600
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 5 9.127778 $456.3900 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 3.483334 $239.8700 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 5.000000 $1150.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 235 309 198.721987 $9936.2100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 4 3.500000 $175.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 14 18 12.126983 $303.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 421 486 1110.129565 $55506.5000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 8.133333 $406.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 189 199 386.420242 $19321.0400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.366667 $9.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 76 82 136.783802 $6839.2000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.433333 $10.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 218 225 390.047621 $19502.4000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.833333 $91.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 5.000000 $125.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 222 247 1639.666664 $81983.3000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 15.857143 $1132.8300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.714286 $265.3500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 4 17.571427 $1255.3100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 17 102.266667 $7305.9300 $71.4400
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Subtotal (Total Children Is Unduplicated) 641 1616 4050.184165 $206015.8100 $50.8700
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Total 1749 4195.399247 $211963.5200 $50.5200
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Number of Children (Unduplicated) With at Least One Authorization 682