Summary Report for FSPSAs Ending During the Report Period Center: 02
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 2954 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 1 1 2.433333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 2.433333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 44 46 26.387213 $1279.7700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.008219 $56.5600 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.105556 $2.0600 $19.5200
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 8 8 6.205479 $91.1000 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.008219 $22.2500 $22.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.266667 $12.0900 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.105556 $12.2300 $115.8600
EXIT -EXIT EXIT ASSESSMENT 27 27 30.002740 $1500.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 8.005479 $600.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 6.005479 $333.3100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 83 83 142.060269 $10654.5400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 47 49 94.000000 $7050.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 35 70.000000 $5250.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 104 105 183.560269 $10187.6100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 35 35 67.000000 $3718.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 36.500000 $2737.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 22.000000 $1650.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.533333 $26.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 1.349696 $69.3900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 16 17 13.115752 $674.2800 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 6.339118 $325.9000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 4.760425 $244.7300 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.416667 $21.4200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.561112 $28.8500 $51.4200
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 7.285714 $374.5600 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.237900 $12.2300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 8 8 3.330897 $171.2400 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 16 16 8.663623 $445.4000 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.189041 $9.7200 $51.4000
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 19 6.796727 $349.4300 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.416667 $21.4200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 8.378919 $430.7600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 3.151978 $162.0400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 31 31 13.782334 $708.5500 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.377778 $19.4200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.377778 $19.4200 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.401141 $20.6200 $51.4000
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 0.377778 $19.4200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 2.650000 $118.8800 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 10.142857 $536.8600 $52.9300
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Subtotal (Total Children Is Unduplicated) 307 610 808.858380 $51442.6700 $63.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 50 52 62.561341 $312806.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.833333 $41.6700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.180822 $12.5400 $69.3400
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 2.214156 $512.8500 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 30 23.059232 $1152.9700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 3.505556 $175.2800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 219 249 364.376187 $18218.8000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 100 164.866664 $8243.3300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 3.300000 $165.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.266667 $31.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 28 37.342855 $1867.1400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 193 204 290.542854 $14527.1300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 3 3 5.833333 $291.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.333333 $83.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 28.719048 $1435.9500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 207 219 1295.328582 $64766.3800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 17 17 75.714286 $3785.7200 $50.0000
INTR -T1013 INTERPRETER 20 31 69.184051 $3459.2000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 279 534 1882.281685 $18822.8000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 57 343.404764 $24711.4200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 18.000000 $1295.2800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 10.714286 $617.1400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 56 59 348.285717 $25062.6500 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 2 2 1.811111 $32.8400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 70 452.580957 $32567.7400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.142857 $82.2400 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 3.428571 $47.8600 $13.9600
TRAV -TRAVS Travel by mile 320 661 105174.177499 $46802.5100 $0.4500
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Subtotal (Total Children Is Unduplicated) 378 2343 110670.989747 $582767.6200 $5.2700
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Total 2954 111482.281460 $634210.2900 $5.6900
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Number of Children (Unduplicated) With at Least One Authorization 451