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 4586 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 61 62 113.001587 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 61 62 113.001587 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 22 24.545205 $1190.4400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.000000 $168.3000 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.5100 $19.5100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $21.0400 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
EXIT -EXIT EXIT ASSESSMENT 4 4 3.016667 $150.8400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 13 14 25.785714 $1933.9300 $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 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 15 15 28.285714 $2121.4300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 35 35 70.000000 $3885.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 11 11 21.000000 $1165.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 36 43 84.000000 $6300.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 17 22 43.000000 $3225.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.112329 $5.7700 $51.4000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.8200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 113 192 336.745629 $22391.9500 $66.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 8.307502 $41537.0000 $4999.9400
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 360 413 455.553162 $22777.6500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 25 33 6.109596 $305.4600 $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 8 8 12.342856 $308.5700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 60 63 147.047623 $7352.4100 $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 73 75 144.905558 $7245.2900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 9 9 16.216667 $810.8400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.533333 $88.3300 $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 5 5 8.499999 $212.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 48 49 411.799999 $20589.9900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 84 89 576.980963 $28849.0300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 10 78.380954 $3919.0600 $50.0000
INTR -T1013 INTERPRETER 143 168 475.178571 $23758.9400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1109 1444 9589.919450 $95899.1500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 89.714286 $6455.8400 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.800000 $57.5700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 12 12 80.947620 $5824.9900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 3.714286 $267.2800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 10.428571 $750.4400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 15 108.433334 $7802.8700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.571429 $832.6800 $71.9600
TRAV -TRAVS Travel by mile 1128 1478 9636.681352 $4288.3200 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1226 4332 22712.211046 $320659.6800 $14.1200
-------------------------------------------------------------------------------------------------------------------------------------
Total 4586 23161.958262 $343051.6200 $14.8100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1291