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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 8101 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 70 70 99.495239 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 44.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 72 72 143.495239 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 55 59 61.703424 $2992.6100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 19 19 18.748858 $1051.8100 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 10 10 25.752380 $407.9200 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 3.000000 $58.5300 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 6 6 7.000000 $165.6900 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 6.000000 $88.0800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 13.533333 $298.6800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 15.533333 $111.8400 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 13.533333 $391.3800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 5.000000 $225.4000 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.000000 $41.4300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 14 14 25.000000 $526.0000 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 4.285714 $372.6000 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 2 2 2.000000 $150.2600 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.197261 $8.9400 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 11.535420 $1335.9100 $115.8100
EXIT -EXIT EXIT ASSESSMENT 61 64 64.865362 $3243.2800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 12 21.000000 $1575.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 13 17 33.500000 $2512.5000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 35.500000 $1970.2500 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 4 8.000000 $444.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 61 61 120.000000 $9000.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 33 34 68.000000 $5100.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 46 46 89.500000 $6712.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 13 25.000000 $1875.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 64 65 127.500000 $9562.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 23 24 48.000000 $3600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 334 337 662.642857 $36776.6800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 141 148 289.066667 $16043.2000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 364 477 918.320482 $68874.0500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 123 146 288.500000 $21637.5000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 9 9 10.000000 $514.1000 $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
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.8200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.246576 $64.0900 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.641096 $9.6900 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 8.000000 $411.2800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.298631 $15.3500 $51.4000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.224658 $54.9400 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 10 11 75.771428 $4010.5800 $52.9300
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 4.571429 $241.9600 $52.9300
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Subtotal (Total Children Is Unduplicated) 854 1681 3164.972242 $205745.2700 $65.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 47 51 48.303120 $241514.5000 $4999.9800
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 6.428571 $445.8200 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 8.106849 $1877.7000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 432 494 521.371541 $26068.5700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 22 27 1.587676 $79.3500 $49.9800
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 69 75 99.585128 $2489.6300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 239 252 453.529367 $22676.4800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 21 22 52.800000 $2640.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 11 13 13.288889 $332.2200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 103 107 216.522222 $10826.1100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 10 10 19.435712 $971.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 7.288889 $182.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 103 106 192.069842 $9603.5000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 7 7 10.166666 $508.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 6 6 9.755556 $243.8900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 163 167 308.633332 $15431.6600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 15 16 31.694443 $1584.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 11 41.100001 $1027.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 96 100 608.900002 $30445.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 951 1014 6703.514245 $335175.8400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 77 78 533.828570 $26691.4700 $50.0000
INTR -T1013 INTERPRETER 214 277 506.530156 $25326.5100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1201 1572 9697.670579 $96976.7400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 59 62 387.195236 $27862.6000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 20.428571 $1470.0400 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 1.133333 $81.5500 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 13.857143 $997.1600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 101 105 599.930948 $43171.0600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 23.057143 $1659.2000 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 4 4 26.114287 $1879.1800 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 11.000000 $791.5600 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.227397 $26.1000 $114.7600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 5 5 3.580822 $64.9200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 116 719.904756 $51804.3500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 15 15 100.790475 $7252.8900 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 6 53.790476 $3870.7600 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 5 5 44.428571 $620.2200 $13.9600
TRAV -TRAVS Travel by mile 1210 1597 9755.199152 $4341.0600 $0.4400
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Subtotal (Total Children Is Unduplicated) 1383 6348 31854.749666 $999930.6000 $31.3900
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Total 8101 35163.217147 $1205675.8800 $34.2900
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Number of Children (Unduplicated) With at Least One Authorization 1612