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 1612 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 22 22 10.419840 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 22 10.419840 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 14.857143 $289.8600 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $47.3400 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.611111 $13.4900 $22.0700
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.4500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 5 3.611111 $104.4300 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 7 7 5.611111 $77.4900 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 4.000000 $84.1600 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $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 -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.388889 $19.9900 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.755556 $38.8500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 12.353175 $635.0800 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.8200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.338889 $17.4200 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.383333 $19.7100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.461111 $23.7100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 0.288889 $14.8500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 15 16 17.629366 $906.3300 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 12.531746 $644.2600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.811111 $41.7000 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.411111 $21.1300 $51.4100
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Subtotal (Total Children Is Unduplicated) 68 96 115.043652 $5017.4500 $43.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 2.000000 $10000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.283333 $164.1700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 4.000000 $926.4800 $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 19 20 174.590474 $8729.5300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 172 179 1213.997218 $60699.8200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 11 11 70.028574 $3501.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 86.000001 $6188.5600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 12 12 64.885714 $4669.1800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 35 41 264.906351 $19062.6400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 4 24.000000 $1727.0400 $71.9600
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Subtotal (Total Children Is Unduplicated) 592 1494 3804.543448 $210217.2500 $55.2500
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Total 1612 3930.006940 $215234.7100 $54.7700
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Number of Children (Unduplicated) With at Least One Authorization 622