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: 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 7085 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 72 73 159.511906 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.000000 $74.4000 $37.2000
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Subtotal (Total Children Is Unduplicated) 73 74 161.511906 $74.4000 $0.4600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 28 32.578538 $1580.0600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 17 17 23.752382 $1332.5100 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 15.857143 $309.3700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 13.857143 $328.0000 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 13.857143 $203.4200 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 13.857143 $305.8300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 13.857143 $99.7700 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 2.466667 $25.7800 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 13.857143 $400.7500 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 13.857143 $624.6800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 13.857143 $191.3700 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 32.799218 $690.0900 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 11.587475 $1341.9500 $115.8100
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 281 285 561.500000 $31163.2500 $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 351 468 925.566667 $69417.5000 $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 12 13 14.000000 $719.7400 $51.4100
OCTH -97166 OT EVAL MODERATE 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 -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.112329 $5.7700 $51.4000
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
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 4.505024 $68.0700 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.000000 $359.8700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 4.947554 $254.3500 $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 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 70.428572 $3727.7800 $52.9300
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Subtotal (Total Children Is Unduplicated) 699 1400 2822.332523 $185371.7000 $65.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 20 23.860927 $119304.0000 $4999.9700
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 14.609393 $3383.8300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 367 421 463.553162 $23177.6500 $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 44 45 42.365363 $1059.1300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 192 206 412.375397 $20618.7600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 18 18 37.005557 $1850.2900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 9 9 13.609523 $340.2400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 64 149.514290 $7475.7400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 6 6 9.600000 $480.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 4 6.166667 $154.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 74 76 145.505558 $7275.2900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 9 9 16.216667 $810.8400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 4 6.266667 $156.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 137 145 294.914285 $14745.7100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 15 16 31.716666 $1585.8300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 9.766666 $244.1700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 127 135 969.166666 $48458.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 804 863 5917.857177 $295892.6900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 116 124 878.880955 $43944.0500 $50.0000
INTR -T1013 INTERPRETER 159 186 509.500000 $25475.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1109 1444 9589.919450 $95899.1500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 44 303.419045 $21834.0200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 11.571429 $832.6800 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.800000 $57.5700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 90 95 637.352385 $45863.8600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 14.714286 $1058.8400 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 17.857142 $1285.0000 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 9.285714 $668.2000 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 2.806393 $322.2000 $114.8100
SENS -V5264 EARMOLD 3 3 2.663622 $48.2900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 117 122 896.280952 $64496.3500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 12 12 84.000002 $6044.6300 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 53.714285 $3865.2800 $71.9600
TRAV -TRAVS Travel by mile 1128 1478 9636.681352 $4288.3200 $0.4500
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Subtotal (Total Children Is Unduplicated) 1255 5611 31221.627239 $863402.2200 $27.6500
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Total 7085 34205.471668 $1048848.3300 $30.6600
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Number of Children (Unduplicated) With at Least One Authorization 1420