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: 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 2791 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 11 11 14.521428 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 14.521428 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 30 30 29.172222 $1636.5600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 16 17 13.200000 $209.0900 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 19 19 15.911111 $310.4300 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.011111 $44.2000 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 11 11 12.108732 $267.2400 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.866667 $16.4500 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 4.155556 $120.1800 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 56 56 29.905551 $412.9900 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 13 13 12.188889 $256.4500 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $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 11 11 22.000000 $1221.0000 $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 16 18 36.000000 $2700.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 18 19 19.000000 $976.7900 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 0.233333 $11.9900 $51.4000
OCTH -97165 OT EVAL LOW COMPLEXITY 23 26 17.155556 $881.9700 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 2.683333 $137.9500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 17 17 10.011110 $514.6700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 16 16.461111 $846.2700 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 13 13 6.927778 $356.1600 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.8500 $51.4000
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 5.227779 $268.7700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 82 91 68.583334 $3525.8700 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 2 0.483333 $24.8500 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 7 3.338889 $171.6500 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.127777 $6.5700 $51.3800
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 55 60 35.888888 $1845.0400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.300000 $118.2400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 3.000000 $154.2300 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 3.477777 $178.7900 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 7 7 32.000000 $1645.1200 $51.4100
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Subtotal (Total Children Is Unduplicated) 363 487 426.919837 $20171.3800 $47.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.588889 $40.8400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 240 318 271.491685 $13574.6800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 7 7.250000 $362.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 8 13.316666 $332.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 342 384 858.280947 $42914.0300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 9.166666 $458.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 167 178 348.990474 $17449.5100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.633333 $31.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 67 72 138.004761 $6900.2300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.866667 $43.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.700000 $92.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 201 223 406.785709 $20339.2600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 3.233333 $161.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 2.666666 $66.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 106.571430 $5328.5700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 4.000000 $200.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 638 672 5216.141292 $260806.9700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 98 101 749.495244 $37474.7500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 66 74 588.961906 $42381.6800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 38 40 301.428574 $21690.7800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 15.571429 $1120.5200 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.011111 $18.3300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 156 172 1202.714296 $86547.2300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 17.142857 $1233.6000 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 8 109.428571 $6303.0900 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 10.857143 $625.3700 $57.6000
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 1 1 7.571429 $436.1100 $57.6000
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Subtotal (Total Children Is Unduplicated) 887 2293 10401.871078 $577697.3200 $55.5400
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Total 2791 10843.312343 $597868.7000 $55.1400
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Number of Children (Unduplicated) With at Least One Authorization 918