Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2478 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 1 1 0.084932 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.084932 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 29 31 21.770320 $1055.8500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.1600 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $47.0000 $23.5000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.722222 $32.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.400000 $46.0000 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.494444 $24.7200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 39 39 43.473972 $2173.7100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 6 12.000000 $666.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 107 107 191.780034 $14383.5200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 28 28 57.214286 $4291.0700 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 5 5 11.000000 $825.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 127 134 246.494320 $13680.4500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 1.500000 $83.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 39 43 87.000000 $6525.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 1.936150 $98.8400 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.488889 $24.9600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 0.931964 $47.5800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 26 26 14.749772 $752.9800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 1.397261 $71.3300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 9 9 7.669591 $391.5400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 19 9.053273 $462.1700 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 10.000000 $510.5000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.244444 $63.5300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 27 28 12.187520 $622.1700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.183333 $9.3600 $51.0400
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 15 16 13.962111 $622.0100 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.241096 $55.2900 $44.5500
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Subtotal (Total Children Is Unduplicated) 259 540 770.895002 $48758.5400 $63.2500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 39 41 44.697913 $223489.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.494445 $124.7300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.050000 $471.5000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 52 52 47.482540 $2374.1300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 7 8 11.500000 $575.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.755556 $68.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 212 240 500.944450 $25047.2500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 4.714286 $235.7200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.800000 $45.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 112 114 227.947622 $11397.3900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 5 5 11.733334 $586.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.733333 $18.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 22 60.060316 $3003.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.533333 $63.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 181 192 342.843655 $17142.2000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 6 6 7.866667 $393.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.566667 $14.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 219 224 1545.522208 $77276.2100 $50.0000
INTR -T1013 INTERPRETER 15 23 73.912393 $3695.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 213 374 1871.433318 $18714.3500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 53 53 450.142850 $32158.2400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 40.142856 $2867.8100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 6.642857 $379.9700 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 11.142857 $796.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 36 36 312.919046 $22354.9600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 15.071428 $1076.7100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 31.280953 $1788.0200 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 2.285714 $130.6500 $57.1600
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.400000 $319.2000 $228.0000
SENS -V5264 EARMOLD 2 2 1.811111 $32.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 66 68 531.890471 $37998.3200 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 6 6 61.857142 $858.5800 $13.8800
TRAV -TRAVS Travel by mile 231 438 96762.664792 $43059.3900 $0.4500
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Subtotal (Total Children Is Unduplicated) 297 1937 102993.844113 $528625.6600 $5.1300
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Total 2478 103764.824047 $577384.2000 $5.5600
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Number of Children (Unduplicated) With at Least One Authorization 356