Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 6717 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 1 1 9.000000 $333.0000 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 82 84 238.724602 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.466667 $54.2700 $37.0000
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Subtotal (Total Children Is Unduplicated) 84 86 249.191269 $387.2700 $1.5500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 25 18.495890 $897.0500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 3.000000 $70.5000 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $47.0000 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.000000 $43.7400 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $47.0000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.000000 $29.3700 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.000000 $86.1600 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $89.5200 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $27.4200 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 4.005479 $83.6700 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $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 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 233 235 464.285714 $34821.4300 $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 -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 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 14.642857 $219.6400 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 4.000000 $204.2000 $51.0500
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 11.068493 $565.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.402740 $71.6100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 13.285714 $591.8800 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.221918 $9.8900 $44.5700
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 15 15 79.622222 $4185.7400 $52.5700
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Subtotal (Total Children Is Unduplicated) 757 1455 2797.745312 $181860.7800 $65.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 22 13.572602 $67863.5000 $5000.0400
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 11 15.590020 $779.5000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.233790 $153.8200 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 13 13 18.285714 $4205.7100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 330 364 405.741878 $20287.0900 $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 48 49 46.534770 $1163.3700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 174 190 335.671426 $16783.5600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 22 23 36.132539 $1806.6200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 9.733333 $243.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 65 70 114.411107 $5720.5400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 6 6 6.677777 $333.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 10.252380 $256.3100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 63 68 105.916668 $5295.8400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 11 12 11.399998 $569.9900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 7.666666 $191.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 128 135 225.689684 $11284.5000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 17 18 21.694443 $1084.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 8.533333 $213.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 22 22 27.180949 $1359.0700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 860 922 5727.885644 $286394.4900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 48 52 261.423805 $13071.1900 $50.0000
INTR -T1013 INTERPRETER 137 160 368.861906 $18443.1000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1044 1363 7555.706786 $75557.1300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 40 217.704762 $15552.8500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 21.838096 $1560.1100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 75 78 454.652382 $32480.3500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.428571 $102.0600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.733333 $213.4000 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 7 7 37.142857 $2653.4800 $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 14.802871 $266.4500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 99 658.471417 $47041.2700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 28.142857 $2010.5300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 4 21.571428 $1541.0700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 18 18 122.142855 $8725.8900 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 27.714285 $384.6700 $13.8800
TRAV -TRAVS Travel by mile 1043 1369 7519.668688 $3346.2500 $0.4400
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Subtotal (Total Children Is Unduplicated) 1185 5176 24469.425323 $649705.2900 $26.5500
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Total 6717 27516.361904 $831953.3400 $30.2300
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Number of Children (Unduplicated) With at Least One Authorization 1399