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: 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 1723 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 26 26 18.684921 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 26 26 18.684921 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.000000 $167.1300 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $23.5000 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.5000 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.5800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.5000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 6 2.072222 $20.2900 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 2.000000 $19.5800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 8 3.472222 $99.7200 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $89.5200 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 7 3.072222 $42.1200 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 5.000000 $104.4500 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 33 33 53.750000 $2687.5000 $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 -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 8.457936 $431.7800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.1000 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.011111 $0.5700 $51.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.038889 $1.9900 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 13 11.600000 $592.1800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.1000 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 17.714285 $931.2500 $52.5700
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Subtotal (Total Children Is Unduplicated) 73 113 147.188887 $7097.6900 $48.2200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.405556 $70.2800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 249 329 215.599773 $10780.1400 $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 13 15 19.904761 $497.6200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 395 442 942.789875 $47139.5000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.800000 $140.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 4.499999 $112.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 214 220 376.519047 $18825.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.966668 $149.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 73 77 121.107141 $6055.3500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.133334 $28.3400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 212 220 401.247608 $20062.3300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.166667 $58.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 6.066667 $151.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 15 15 61.038095 $3051.9100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 201 217 1684.552375 $84227.6400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.571429 $28.5700 $50.0000
INTR -T1013 INTERPRETER 1 1 3.000000 $150.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 11.714286 $836.8700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 20.000000 $1428.8000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.571429 $32.6600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 14 107.857142 $7705.3200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 12.714285 $908.3100 $71.4400
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Subtotal (Total Children Is Unduplicated) 644 1584 4007.726137 $203076.2300 $50.6700
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Total 1723 4173.599945 $210173.9200 $50.3600
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Number of Children (Unduplicated) With at Least One Authorization 693