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 1820 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 2 2 1.700000 $95.3700 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 2.677778 $42.4200 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.127777 $22.0000 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.800000 $18.9400 $23.6700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.422222 $9.3200 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.700000 $6.1700 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.700000 $20.2400 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.700000 $31.5600 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 20 20 13.238888 $182.8300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 16.985714 $357.3800 $21.0400
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
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 3 4 8.000000 $600.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.333333 $68.5500 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.183333 $9.4200 $51.4000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.744445 $38.2700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 2.650000 $136.2400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 3.000000 $154.2300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 1.333333 $68.5500 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.500000 $25.7100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 1.588888 $81.6800 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 8.161111 $419.5600 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.8200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 9.205555 $473.2500 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 7.571429 $389.2500 $51.4100
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Subtotal (Total Children Is Unduplicated) 78 100 98.323806 $4051.8800 $41.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $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 407 450 1022.990471 $51149.5000 $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 219 228 425.509521 $21275.4600 $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 17 17 133.280952 $6664.0500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 235 249 1655.176190 $82758.8400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 20 142.376191 $7118.8200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 12 89.071429 $6409.5800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 9 9 77.357143 $5566.6200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 6.428571 $462.6000 $71.9600
SENS -V5264 EARMOLD 1 1 0.033333 $0.6000 $18.1100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 35 36 258.071431 $18570.8200 $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 1 2 6.285715 $362.0600 $57.6000
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Subtotal (Total Children Is Unduplicated) 671 1702 4714.601403 $250318.1700 $53.0900
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Total 1820 4834.411716 $254370.0500 $52.6200
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Number of Children (Unduplicated) With at Least One Authorization 697