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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 3225 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 12.134921 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 26 26 12.134921 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 26 26 35.678571 $2001.5700 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.127778 $2.0200 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 28 28 39.625397 $773.0900 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 15 15 15.166667 $359.0000 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 8 8 12.142857 $178.2600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 10 7.505555 $165.6500 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 16 15.887301 $114.3900 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 7 7 7.000000 $73.1500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 31 31 28.392856 $821.1200 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 7 7 6.166667 $277.9900 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 60 60 53.005555 $732.0100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 16 17 20.309524 $427.3100 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.444444 $110.7800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $115.8100
EXIT -EXIT EXIT ASSESSMENT 8 8 9.000000 $450.0000 $50.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 30.000000 $1665.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 12 12 24.000000 $1800.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 15 15 15.000000 $771.1500 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 0.316667 $16.2800 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 37 38 27.566666 $1417.2000 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 6 4.800000 $246.7700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 8.661111 $445.2700 $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 16 17.333333 $891.1100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 25 27 18.905555 $971.9300 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 1.400000 $71.9700 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.400000 $20.5600 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 6 1.144445 $58.8400 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.250000 $12.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 20 21 19.484126 $1001.6800 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 72 74 55.481746 $2852.3200 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.188889 $9.7100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 7 3.722222 $191.3600 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 0.416666 $21.4200 $51.4000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 67 69 52.003175 $2673.4800 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 4 4.000000 $205.6400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.266667 $65.1200 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.394444 $123.1000 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 2.000000 $102.8200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 10 13.444445 $603.1200 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 8 9 67.857142 $3591.6800 $52.9300
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Subtotal (Total Children Is Unduplicated) 398 604 634.490471 $27101.1500 $42.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 4 4 8.361111 $579.8400 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 2.022222 $140.2400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 13.888889 $3216.9500 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 198 289 192.539498 $9627.1400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 8.941667 $223.5400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 427 479 975.877560 $48793.8900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.766667 $138.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.333333 $33.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 210 223 368.102383 $18405.1300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 98 104 240.433332 $12021.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.466667 $61.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 240 260 419.333329 $20966.6500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.166666 $104.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 31 33 236.995239 $11849.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 667 703 4897.052386 $244852.7200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 101 104 762.814286 $38140.7200 $50.0000
INTR -T1013 INTERPRETER 2 2 2.171429 $108.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 2.714285 $27.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 71 79 514.790480 $37044.3200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.714286 $51.4000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 67 70 437.666665 $31494.5000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.571429 $113.0800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 8.000000 $460.4800 $57.5600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 6.000000 $2755.3200 $459.2200
SENS -V5264 EARMOLD 5 5 17.500000 $317.2800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 186 199 1326.942854 $95486.8200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 30.285714 $2179.3700 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 10.571428 $608.9100 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 9.285714 $668.2100 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.000000 $287.8400 $71.9600
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Subtotal (Total Children Is Unduplicated) 942 2595 10513.309519 $585908.9600 $55.7300
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Total 3225 11159.934911 $613010.1100 $54.9300
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Number of Children (Unduplicated) With at Least One Authorization 995