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 1507 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 11 11 11.000000 $617.1000 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 3.000000 $58.5300 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.6800 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.450000 $3.2400 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 2.450000 $70.8500 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 9 8.450000 $116.6900 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.000000 $63.1200 $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 7 7 8.000000 $400.0000 $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 2 2 2.000000 $102.8200 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 6 7 4.405556 $226.4900 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.072222 $3.7100 $51.3900
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.8200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 3.683333 $189.3600 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.127778 $6.5700 $51.4200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.366667 $18.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.327778 $119.6700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 17 19 12.572225 $646.3500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 6 5.327778 $273.9000 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.072222 $3.7100 $51.3900
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 1 1 1.000000 $44.8600 $44.8600
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Subtotal (Total Children Is Unduplicated) 81 99 90.700004 $4282.1600 $47.2100
EI Services, Class # 03
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $69.3500 $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 39 39 213.166666 $10658.3300 $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 127 133 1023.976191 $51198.7900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 33 33 264.971434 $13248.5600 $50.0000
INTR -T1013 INTERPRETER 1 1 2.533333 $126.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 16 114.571429 $8244.5500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 8 9 59.999998 $4317.6100 $71.9600
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 38 248.538096 $17884.8000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 2 11.857143 $853.2400 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.285714 $16.4600 $57.6000
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Subtotal (Total Children Is Unduplicated) 577 1387 3885.088313 $203860.8800 $52.4700
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Total 1507 3997.393871 $208143.0400 $52.0700
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Number of Children (Unduplicated) With at Least One Authorization 610