Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 2702 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 0.633333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.633333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 24 15.337367 $743.8700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.6800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.052055 $1.1500 $22.0900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.755556 $34.2400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.157611 $18.2600 $115.8800
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.428571 $121.4300 $50.0000
EXIT -EXIT EXIT ASSESSMENT 22 22 25.002740 $1250.1400 $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 2.533333 $126.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 1.011111 $51.9800 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 16 17 10.294140 $529.2200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 22 23 8.659285 $445.1700 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.167123 $8.5900 $51.4000
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.186301 $9.5800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 2.685692 $138.0700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.094444 $4.8500 $51.3900
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.055556 $2.8600 $51.4500
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 1.644444 $84.5400 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 15 15 6.942086 $356.8900 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.202740 $10.4200 $51.4000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 14 15 7.792466 $400.6100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 0.249315 $12.8200 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.186301 $9.5800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 2.733181 $140.5100 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.126027 $6.4800 $51.4000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.310882 $15.9800 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 18 18 7.662176 $393.9100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 1.422222 $73.1200 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 30 31 16.500533 $848.2800 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.275190 $65.5600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.133333 $6.8500 $51.4000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.705556 $76.5100 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.571429 $347.8200 $52.9300
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Subtotal (Total Children Is Unduplicated) 263 576 777.010262 $50062.0100 $64.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 30 70.277505 $351386.5000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.957611 $221.8200 $231.6400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 34 42.649710 $2132.4900 $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 193 204 347.176188 $17358.8000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 2.633333 $131.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 94 95 163.038095 $8151.9000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 3.300000 $165.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.800000 $45.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 29.116665 $1455.8300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 178 181 301.071427 $15053.5600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 2.666667 $133.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.533333 $63.3300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 14 14 84.371429 $4218.5800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 160 164 1118.204767 $55910.2100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 31 31 218.285712 $10914.2900 $50.0000
INTR -T1013 INTERPRETER 20 32 77.469765 $3873.4900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 238 493 2105.462624 $21054.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 66 66 541.490476 $38965.6600 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.428571 $174.7600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.428571 $139.8900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 54 55 449.857141 $32371.7200 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 3.000000 $1377.6600 $459.2200
SENS -V5264 EARMOLD 3 3 1.578386 $28.6200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 69 71 495.985712 $35691.1500 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 9.714286 $135.6100 $13.9600
TRAV -TRAVS Travel by mile 267 613 116077.435295 $51654.4600 $0.4500
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Subtotal (Total Children Is Unduplicated) 312 2125 122159.438825 $653214.8200 $5.3500
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Total 2702 122937.082420 $703276.8300 $5.7200
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Number of Children (Unduplicated) With at Least One Authorization 356