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: 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 3009 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 24 24 18.823017 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 18.823017 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 17 17 16.683333 $935.9300 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 7 7 20.596825 $326.2500 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 8 8 9.400000 $183.3900 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 10 10 12.833333 $303.7600 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 2.266667 $50.0300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 8.550000 $61.5600 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 2.033333 $21.2500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 12 12 12.277777 $355.0700 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 3.833333 $172.8100 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 67 67 44.205554 $610.4800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 14 14 13.100000 $275.6200 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.500000 $30.5000 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.500000 $43.4700 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.500000 $37.5700 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.722222 $32.7300 $45.3200
EXIT -EXIT EXIT ASSESSMENT 4 4 4.000000 $200.0000 $50.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1776.0000 $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 13 13 26.000000 $1950.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 14 15 13.677778 $703.1800 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 38 39 27.666668 $1422.3500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 3.316667 $170.5100 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.811111 $41.7000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 4.288889 $220.4900 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 3.795238 $195.1200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.144444 $7.4200 $51.3900
PSTF -97164 PT RE-EVAL EST PLAN CARE 16 17 16.355556 $840.8400 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 26 28 21.094447 $1084.4800 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 4 4 3.083333 $158.5100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.100000 $5.1400 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 5 1.516668 $77.9800 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.250000 $12.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 12 6.700000 $344.4500 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 63 67 50.822221 $2612.7600 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 1.338889 $68.8300 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 4.072222 $209.3500 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.500000 $77.1200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 55 58 40.144444 $2063.8200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 8 8.000000 $411.2800 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.733333 $89.1100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.105556 $5.4300 $51.4300
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 8 9 17.727779 $795.2700 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 7 36.066667 $1909.0100 $52.9300
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Subtotal (Total Children Is Unduplicated) 368 506 484.314287 $21475.6000 $44.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 2.311110 $160.2700 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 3.900000 $903.3200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 209 288 207.517275 $10376.0200 $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 9 10 23.241668 $581.0500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 402 444 924.354542 $46217.7200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 2 5.333334 $266.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 207 220 370.476191 $18523.8100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.600000 $140.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 102 109 194.580955 $9729.0600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.533333 $13.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 215 247 405.322221 $20266.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 9.466668 $236.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 56 59 369.133331 $18456.6900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 557 594 4149.298404 $207465.0400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 133 139 1216.447617 $60822.3900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 2.714285 $27.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 63 69 426.295243 $30676.2300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 68 73 458.098410 $32964.8000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 25.428571 $1829.8400 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 3 3 4.944444 $89.6400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 168 184 1346.224603 $96874.3600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 27.285714 $1963.4900 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 9 55.571426 $3200.9200 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 14.857143 $1069.1200 $71.9600
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Subtotal (Total Children Is Unduplicated) 920 2479 10252.936488 $568822.1100 $55.4800
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Total 3009 10756.073792 $590297.7100 $54.8800
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Number of Children (Unduplicated) With at Least One Authorization 971