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 1754 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 5 5 5.933333 $332.8600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 16.285714 $257.9700 $15.8400
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 6.833333 $161.7400 $23.6700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.588889 $13.0000 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 4.183333 $30.1200 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.705555 $107.1600 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.833333 $127.7300 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 10.088888 $139.3300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 5.833333 $122.7300 $21.0400
EXIT -EXIT EXIT ASSESSMENT 4 4 4.000000 $200.0000 $50.0000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 8 9 4.272223 $219.6400 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.811111 $41.7000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 5.061112 $260.2000 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.083333 $4.2800 $51.3900
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 4 1.200001 $61.7000 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 13 14 11.172222 $574.3600 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.411111 $21.1300 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 7.661111 $393.8600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.322222 $67.9700 $51.4100
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Subtotal (Total Children Is Unduplicated) 79 101 103.607935 $3775.2000 $36.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
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 45 47 302.847617 $15142.4000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 136 149 1073.055554 $53652.8100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 35 38 283.561905 $14178.0900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 2.714285 $27.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 12 87.357144 $6286.2200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 14 15 112.604761 $8103.0400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 29 34 234.561904 $16879.0900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 20.571428 $1480.3300 $71.9600
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Subtotal (Total Children Is Unduplicated) 625 1629 4265.700785 $227149.5500 $53.2500
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Total 1754 4388.131737 $230924.7400 $52.6200
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Number of Children (Unduplicated) With at Least One Authorization 657