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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2639 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 21 21 21.605554 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 21.605554 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 25 25 37.638096 $2111.5000 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 17 17 19.000000 $370.6900 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 8 10.066667 $238.2800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 2.111111 $46.5900 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 5.577778 $40.1600 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 12 12 10.794445 $312.1800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 4.066667 $183.3300 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 49 49 79.327778 $1095.5200 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 11 12.066667 $253.8800 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.244444 $101.7200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $115.8100
EXIT -EXIT EXIT ASSESSMENT 7 7 8.000000 $400.0000 $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
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 22 23 18.094444 $930.2300 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.072222 $55.1200 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.072222 $3.7100 $51.3900
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 6.050000 $311.0300 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 15 15.000000 $771.1500 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 22 22 15.938888 $819.4100 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.127778 $6.5700 $51.4200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.883333 $45.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 9.653175 $496.2700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 81 92 69.861112 $3591.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 6 1.911111 $98.2500 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 1.211111 $62.2600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 33 34 24.616667 $1265.5400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.072222 $106.5300 $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 0.066667 $3.4300 $51.4300
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.733334 $77.7600 $44.8600
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 29.285714 $1550.0900 $52.9300
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Subtotal (Total Children Is Unduplicated) 337 473 546.543653 $25252.2800 $46.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.133333 $666.5000 $4998.7600
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.211111 $14.6400 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 3.000000 $208.0500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 175 237 163.063711 $8153.2900 $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 4.666667 $116.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 365 406 880.500000 $44025.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.933333 $48.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 176 183 370.593652 $18529.7000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.200000 $5.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 80 84 179.619047 $8980.9500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.600000 $15.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 173 188 329.835709 $16491.7600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 3.714286 $185.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.533333 $113.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 45 46 249.433332 $12471.6600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.928571 $46.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 540 567 4415.050015 $220752.4100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 121 124 1075.471439 $53773.5200 $50.0000
INTR -T1013 INTERPRETER 1 1 2.533333 $126.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 62 67 503.495239 $36231.4900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 48 55 358.004760 $25762.0100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 12.714286 $914.9100 $71.9600
SENS -V5264 EARMOLD 2 2 2.000000 $36.2600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 147 156 1229.357940 $88464.5800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 4 46.714285 $3361.5600 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.857143 $164.5700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 10.428571 $750.4400 $71.9600
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Subtotal (Total Children Is Unduplicated) 866 2145 9854.593096 $540923.6800 $54.8900
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Total 2639 10422.742303 $566175.9600 $54.3200
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Number of Children (Unduplicated) With at Least One Authorization 926