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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 7105 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 103 105 215.458729 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 2.377778 $88.4500 $37.2000
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Subtotal (Total Children Is Unduplicated) 105 107 217.836507 $88.4500 $0.4100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 29 31 25.717808 $1247.3100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $112.2000 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 7 7 15.857143 $309.3700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $47.3400 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.000000 $66.2100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $14.4000 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $57.8400 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $90.1600 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $27.6200 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 18.428571 $387.7400 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 1.000000 $75.1300 $75.1300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.093151 $10.7900 $115.8700
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 5.016667 $250.8400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $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 7 12 24.000000 $1800.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 18.000000 $999.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 85 88 169.285714 $12696.4300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 35 36 70.500000 $5287.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 44.000000 $3300.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 11 11 22.000000 $1650.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 59 59 113.785714 $8533.9300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 282 286 563.500000 $31274.2500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 90 91 177.571429 $9855.2100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 350 465 919.500000 $68962.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 119 151 298.071429 $22355.3600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 10.000000 $514.1000 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.032877 $1.6900 $51.4500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.986301 $14.9000 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 13 13 13.000000 $668.3300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.8200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.090411 $107.4700 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.079452 $4.0900 $51.4400
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 8 8 56.076191 $2968.1100 $52.9300
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Subtotal (Total Children Is Unduplicated) 729 1392 2670.592858 $179644.5500 $67.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 19 15.226484 $76132.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 7.405936 $370.3000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 13 13 12.071233 $2795.9300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 373 423 452.929352 $22646.4600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 26 34 8.109596 $405.4600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 47 48 43.498696 $1087.4700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 187 201 326.224599 $16311.2100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 16 18 26.788890 $1339.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 8 9.276190 $231.9100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 57 62 117.120635 $5856.0400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 8 9 12.566666 $628.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 5.083334 $127.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 63 70 108.641020 $5432.0600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 11 11 13.016666 $650.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 4.133333 $103.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 141 155 344.240469 $17211.9900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 14 15 17.455555 $872.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 12.133333 $303.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 124 131 789.409523 $39470.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 792 861 5097.285732 $254864.2300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 105 115 553.509524 $27675.4600 $50.0000
INTR -T1013 INTERPRETER 165 192 417.785716 $20889.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1103 1450 8043.549580 $80435.4800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 35 171.283334 $12325.5500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 8.428571 $606.5200 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 3 3 7.552381 $543.4800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 84 89 451.628569 $32499.1600 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 7 7 48.890476 $3518.1500 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.164384 $18.8700 $114.8200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 3 3 0.693151 $12.5700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 110 113 793.928571 $57131.0900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 12 13 81.857143 $5890.4400 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 5 5 22.571428 $1624.2500 $71.9600
TRAV -TRAVS Travel by mile 1132 1482 8156.180532 $3629.5000 $0.4500
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Subtotal (Total Children Is Unduplicated) 1318 5606 26181.640602 $694100.1800 $26.5100
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Total 7105 29070.069967 $873833.1800 $30.0600
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Number of Children (Unduplicated) With at Least One Authorization 1855