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 4122 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 63 64 120.491265 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.211111 $7.8100 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 67 68 125.235709 $175.5400 $1.4000
Screening, Eval, and Assessment, Class # 02
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) 1 1 1.000000 $14.5800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.5000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $9.7900 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.7200 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $44.7600 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.098630 $8.3700 $84.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $13.7100 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $20.8900 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.054795 $2.4700 $45.0000
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 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $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 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 16 16 32.000000 $2400.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 17 17 34.000000 $2550.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 5.000000 $375.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 54 54 108.000000 $5994.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 5.000000 $277.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 32 63.000000 $4725.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 3.000000 $153.1500 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 141 221 396.155317 $24117.3100 $60.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 3.946119 $19731.0000 $5000.1000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.312329 $21.5100 $68.8500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $690.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 323 357 401.141878 $20057.0900 $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 40 41 35.401436 $885.0300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 154 180 327.984131 $16399.2300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 14 14 25.977779 $1298.9000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.400000 $60.0000 $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 2 2 2.466666 $61.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 132 227.157938 $11357.9100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 12 12 14.844446 $742.2300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.833333 $145.8300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.000000 $50.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 55 59 359.890481 $17994.5300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 4.285714 $214.2900 $50.0000
INTR -T1013 INTERPRETER 116 131 354.352379 $17717.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 992 1342 7720.449002 $77204.4400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 8 41.000001 $2929.0300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 8.571429 $612.3400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 5 38.142859 $2724.9100 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 4.285714 $306.1700 $71.4400
SENS -V5264 EARMOLD 1 1 0.109589 $1.9700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 23 207.428570 $14818.6800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.285714 $306.1700 $71.4400
TRAV -TRAVS Travel by mile 1003 1344 7654.158528 $3406.1000 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1141 3833 17681.774653 $221404.0300 $12.5200
-------------------------------------------------------------------------------------------------------------------------------------
Total 4122 18203.165679 $245696.8900 $13.5000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1246