Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 7608 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 94 95 139.992857 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 94 95 139.992857 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 33 37 36.634161 $1776.7600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 21 21 22.140182 $1242.0600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 12 12 32.933333 $521.6600 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 4.000000 $78.0400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $47.3400 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 3.005556 $44.1200 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 10.933333 $241.3000 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 15.938889 $140.4200 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 12.133333 $350.9000 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 2.005556 $90.4100 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $27.6200 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 11 20.138889 $423.7200 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 2 0.933333 $56.9300 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.366667 $16.6200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.287671 $33.3200 $115.8200
EXIT -EXIT COS Exit 94 99 72.528769 $3626.4300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 0.142857 $10.7200 $75.0200
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 14 28.000000 $2100.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 9 18.000000 $999.0000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 46 47 92.500000 $6937.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 22 22 44.000000 $3300.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 71 71 141.000000 $10575.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 13 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 62 62 121.000000 $9075.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 10 10 19.500000 $1462.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 337 344 680.076908 $37744.2700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 110 115 230.000000 $12765.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 403 499 990.576908 $74293.2700 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 76 97 194.000000 $14550.0000 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 12.714286 $688.7300 $54.1700
OCTH -97165 OT EVAL LOW COMPLEXITY 7 7 7.000000 $359.8700 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.098630 $107.8900 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 7.000000 $359.8700 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 4.571429 $235.0200 $51.4100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.591780 $8.9400 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 12 12 14.000000 $719.7400 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 6.857143 $352.5200 $51.4100
SPCH -92521TL 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 4 4 3.084932 $158.5900 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 14.142857 $727.0900 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 7.000000 $359.8700 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 852 1582 2929.837402 $190513.0300 $65.0300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 27 31 26.658361 $133291.5000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 11.296673 $2616.5400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 365 416 468.027540 $23401.3800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 50 56 34.965075 $1748.2300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 34 36 37.588814 $939.7200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 216 236 425.468251 $21273.4000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 9 9 18.033333 $901.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 9 9 8.166667 $204.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 100 104 167.216671 $8360.8600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 2.233333 $111.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 9.066667 $226.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 75 76 138.303969 $6915.2100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 7 7 7.100000 $355.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 7 7 7.244444 $181.1100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 126 133 198.590471 $9929.5000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 11 11 12.033334 $601.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 13 13 18.400002 $460.0100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 75 77 443.880959 $22194.0500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 931 996 6286.566687 $314328.3800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 77 82 510.147624 $25507.3800 $50.0000
INTR -T1013 INTERPRETER 175 246 403.945239 $20197.2600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1168 1514 8781.704803 $105380.4600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 63 65 331.104767 $23826.2800 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 9.942857 $715.4900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 85 86 402.114290 $28936.1100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 10.714286 $771.0000 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 3 3 11.428572 $822.3900 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 0.287671 $33.0300 $114.8200
SENS -V5060 BEHIND EAR HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 5 5 3.129681 $56.7400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 118 659.857148 $47483.3200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 10 10 56.714286 $4081.1600 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 9.428572 $678.4700 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 17.428572 $243.3000 $13.9600
TRAV -TRAVS Travel by mile 1211 1555 8836.714328 $3932.3400 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1407 5931 28369.503947 $812083.0800 $28.6300
-------------------------------------------------------------------------------------------------------------------------------------
Total 7608 31439.334206 $1002596.1100 $31.8900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1976