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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 3151 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 18 18 21.486507 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 21.486507 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 24 24 19.016667 $1066.8400 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 22 23 18.466667 $292.5100 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 23 24 17.377778 $339.0400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.800000 $18.9400 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 3.177778 $46.6500 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 9 9 9.828570 $216.9100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 4 2.966667 $26.1400 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 19 19 16.933334 $489.7100 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.700000 $31.5600 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 54 55 31.649998 $437.0800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 22 22 49.390476 $1039.1700 $21.0400
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
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 8 8 16.000000 $888.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 13 15 30.000000 $2250.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 21 21 22.000000 $1131.0200 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 25 26 17.233333 $885.9600 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.183333 $9.4200 $51.4000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 5.255556 $270.1900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.8500 $51.4000
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 12.411112 $638.0600 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.8200 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.344444 $17.7100 $51.4000
PSTF -97164 PT RE-EVAL EST PLAN CARE 14 14 15.000000 $771.1500 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 15 15 7.566666 $389.0000 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 1.177778 $60.5500 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 15 15 10.372222 $533.2300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 86 88 65.327778 $3358.5000 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 2.161111 $111.1000 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.422222 $21.7100 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 2 0.477778 $24.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 4.038889 $207.6400 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.477778 $24.5600 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 70 74 48.444446 $2490.5400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 6.000000 $308.4600 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 2 2.000000 $102.8200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 8 8 5.027778 $258.4800 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 30.857144 $1586.3700 $51.4100
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Subtotal (Total Children Is Unduplicated) 414 547 495.587303 $21697.0700 $43.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 2.133333 $147.9400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 11 11 11.711111 $2712.5300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 240 319 247.453788 $12372.8000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 7 7.250000 $362.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 3.583333 $89.5800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 407 452 1028.990471 $51449.5000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 2.100000 $105.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.500000 $37.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 220 229 430.309521 $21515.4600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.966667 $24.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 74 75 142.799999 $7140.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 239 261 475.223811 $23761.2000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.000000 $100.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 18 18 151.566666 $7578.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 732 786 5386.656350 $269332.8700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 77 81 554.321430 $27716.0900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 84 85 679.671433 $48909.1400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 44 44 332.423811 $23921.2200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 12.571428 $904.6500 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 2 2 1.455555 $26.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 173 188 1330.714287 $95758.1900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 10.142858 $729.8800 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 7 60.714287 $3497.1400 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 12.857143 $740.5700 $57.6000
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Subtotal (Total Children Is Unduplicated) 939 2586 10896.117282 $614187.2400 $56.3700
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Total 3151 11413.191092 $635884.3100 $55.7100
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Number of Children (Unduplicated) With at Least One Authorization 999