Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6562 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
CASE -CASE NON-TCM CASE MANAGEMENT 3 3 4.533333 $167.7300 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 75 76 188.369834 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 5.196825 $192.2800 $37.0000
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Subtotal (Total Children Is Unduplicated) 81 82 198.099992 $360.0100 $1.8200
Screening, Eval, and Assessment, Class # 02
AACRS -92597GN AAC RE-EVAL BY LICENSED SLP 1 1 1.000000 $52.6300 $52.6300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 29 29 33.001892 $1600.5800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $23.5000 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.5000 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.1600 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.5000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $19.5800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $57.4400 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $44.7600 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 4.098630 $347.7300 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $13.7100 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.000000 $62.6700 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.054795 $92.4700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 35 35 70.000000 $3500.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 12 12 24.000000 $1800.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 36.000000 $1998.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 233 234 461.000000 $34575.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 37 37 73.000000 $5475.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 136 137 268.500000 $20137.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 11 11 20.000000 $1500.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 16 16 31.500000 $2362.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 472 476 928.785714 $51547.6100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 38 38 71.500000 $3968.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 238 255 488.928571 $36669.6500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 35 35 68.500000 $5137.5000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 14.857143 $758.4600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 4.642857 $69.6400 $15.0000
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.084932 $4.3300 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 12.000000 $612.6000 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 1.556165 $79.4500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 4.000000 $178.2000 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.158904 $7.0800 $44.5800
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.428571 $337.9500 $52.5700
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Subtotal (Total Children Is Unduplicated) 756 1437 2710.598174 $178100.6600 $65.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 26 32.258057 $161291.0000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 3.500000 $175.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 9 10.518004 $525.9000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.312329 $90.3700 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 16 16 17.000000 $3910.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 334 369 413.641878 $20682.0900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 16 29 1.613703 $80.6700 $49.9900
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 42 43 38.401436 $960.0300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 155 181 328.984131 $16449.2300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 14 14 25.977779 $1298.9000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 4.633333 $115.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 59 97.445233 $4872.2400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 5 5 9.244445 $462.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 62 65 116.645236 $5832.2600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 5 5 8.400001 $420.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 5.099999 $127.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 127 137 236.524604 $11826.2400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 12 12 14.844446 $742.2300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 8.466666 $211.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.000000 $50.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 836 909 5693.023817 $284651.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 39 44 269.400005 $13469.9900 $50.0000
INTR -T1013 INTERPRETER 142 162 417.057141 $20852.8500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 992 1344 7732.449002 $77324.4400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 37 225.919048 $16139.6600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 13.428572 $959.3300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 71 74 473.014294 $33792.1100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 4 34.714285 $2479.9900 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 10 10 88.933333 $6353.3900 $71.4400
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 5 5 6.216830 $111.9000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 93 99 675.438096 $48253.2700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 22.571429 $1612.5000 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 5.857143 $418.4300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 9 9 76.000001 $5429.4300 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 5 5 23.857144 $331.1400 $13.8800
TRAV -TRAVS Travel by mile 1003 1347 7690.729957 $3422.3700 $0.4400
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Subtotal (Total Children Is Unduplicated) 1180 5043 24826.121377 $746409.1500 $30.0700
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Total 6562 27734.819543 $924869.8200 $33.3500
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Number of Children (Unduplicated) With at Least One Authorization 1725