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 4924 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 84 84 89.540476 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 84 84 89.540476 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 27 26.323485 $1276.6900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 4.106849 $230.3900 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 5.000000 $79.2000 $15.8400
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 0.366667 $16.6200 $45.3200
EXIT -EXIT COS Exit 89 92 66.028769 $3301.4300 $50.0000
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 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1350.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 20 20 39.000000 $2164.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 8 9 18.000000 $999.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 23 31 61.000000 $4575.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $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
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 5.000000 $257.0500 $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
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.428571 $73.4400 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 172 229 294.111484 $17587.2700 $59.8000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 13.857143 $69285.5000 $4999.9800
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 364 415 467.027540 $23351.3800 $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 8 8 6.566667 $164.1700 $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 4 4 7.466667 $186.6700 $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 5 5 5.633333 $140.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 125 132 196.557138 $9827.8300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 11 11 12.033334 $601.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 11 11 15.800002 $395.0100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 44 46 279.185718 $13959.2800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 82 88 536.242861 $26812.1300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 15 96.757144 $4837.8600 $50.0000
INTR -T1013 INTERPRETER 151 218 356.659524 $17832.9800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1168 1514 8781.704803 $105380.4600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 13 70.238096 $5054.3300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 12 12 65.280953 $4697.6100 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 9.142858 $657.9200 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 1 1 1.266667 $22.9700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 21 116.319048 $8370.3200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 2.714286 $195.3200 $71.9600
TRAV -TRAVS Travel by mile 1209 1553 8830.285756 $3929.4800 $0.4500
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Subtotal (Total Children Is Unduplicated) 1378 4611 20704.648984 $337000.2700 $16.2800
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Total 4924 21088.300944 $354587.5300 $16.8100
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Number of Children (Unduplicated) With at Least One Authorization 1496