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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2970 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 11.197618 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 23 23 11.197618 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 9.783333 $548.8400 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 42 43 69.571429 $1357.3400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 16 16 16.000000 $378.7200 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 13 13 13.000000 $190.8400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 17 18 14.522222 $320.5100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 17 13.538888 $97.4800 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 12 12 12.000000 $125.4000 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 25 26 18.838888 $544.8200 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 13 14 15.000000 $676.2000 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 40 40 33.061110 $456.5700 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 22 23 23.000000 $483.9200 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $61.0000 $61.0000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 4.800000 $217.5400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
EXIT -EXIT EXIT ASSESSMENT 9 9 12.000000 $600.0000 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
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 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 27 27 54.000000 $2997.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 25 25 50.000000 $3750.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 8.000000 $600.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 19 21 21.000000 $1079.6100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 19 19 14.400000 $740.3000 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 5.022222 $258.1900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 24 25 28.342064 $1457.0700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 18 18 19.866667 $1021.3500 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 11 11 6.283333 $323.0200 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 1.383333 $71.1200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 11 11 6.194444 $318.4500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 17 17 7.005557 $360.1600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.505556 $25.9900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 68 71 61.296033 $3151.2300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.588889 $30.2800 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 1.116667 $57.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 6.622222 $340.4500 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 1.811111 $93.1100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.477778 $24.5600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 53 55 43.809523 $2252.2500 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.811111 $144.5200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 3.488889 $179.3600 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.411111 $72.5400 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.594445 $71.5300 $44.8600
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 7.285714 $385.6300 $52.9300
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Subtotal (Total Children Is Unduplicated) 359 603 630.432539 $27093.8000 $42.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.000000 $15000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 3.433333 $171.6700 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.811111 $56.2500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 4.000000 $277.4000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 5.000000 $1158.1000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 188 263 159.463707 $7973.2700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 2 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 8.033333 $200.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 392 438 869.911889 $43495.5200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.833333 $141.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.133333 $28.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 188 196 328.633338 $16431.6900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.433333 $21.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 94 98 185.709522 $9285.4700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 192 202 334.242852 $16712.1200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 2.857143 $142.8600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.600000 $65.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 23 24 195.161902 $9758.1000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 666 704 5022.025798 $251101.2500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 66 68 521.200003 $26060.0100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 72 75 471.638096 $33939.0800 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 7.000000 $503.7200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 57 64 388.919043 $27986.6100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.428571 $318.6800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.571429 $400.9200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 159 173 1264.859526 $91019.2800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 7 55.000000 $3957.8000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 2 12.142857 $873.8000 $71.9600
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Subtotal (Total Children Is Unduplicated) 879 2344 9861.043452 $557131.0800 $56.5000
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Total 2970 10502.673609 $584224.8900 $55.6300
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Number of Children (Unduplicated) With at Least One Authorization 952