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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2878 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 2 2 2.666667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.666667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 35 35 24.552511 $1190.8000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 8.000000 $448.8000 $56.1000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 8.000000 $189.3600 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 2.459512 $36.1100 $14.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.261111 $11.8300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.261111 $30.2400 $115.8100
EXIT -EXIT COS Exit 5 5 3.750000 $187.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 8 12.500000 $937.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 1.505479 $83.5600 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 78 83 128.571227 $9642.8600 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 32 32 59.000000 $4425.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 32 33 63.000000 $4725.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 10 10 19.500000 $1462.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 88 102 169.571227 $9411.2200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 36 36 69.500000 $3857.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 18 27 48.500000 $3637.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 14 17 34.000000 $2550.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.669558 $34.4200 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 25 26 12.485541 $641.8900 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.094444 $4.8500 $51.3900
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 6.978408 $358.7600 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 12.857143 $660.9800 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 1.136986 $58.4500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 9 2.178843 $112.0200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 2.373136 $122.0000 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.500000 $25.7100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 20 21 15.080821 $775.3000 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 10 10 3.442085 $176.9500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 0.311111 $15.9900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 27 28 7.404642 $380.6900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.094444 $4.8500 $51.3900
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.079452 $4.0900 $51.4400
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 0.342466 $17.6000 $51.4000
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.347945 $17.8900 $51.4200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 15.242922 $783.6400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.136986 $7.0400 $51.4200
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.329604 $16.9400 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 0.123288 $6.3400 $51.4200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 2 12.857142 $660.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 280 560 759.004624 $48500.8400 $63.9000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 40 40 60.771166 $303856.5000 $5000.0100
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 51 55 53.146372 $2657.3300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 10 11.263889 $563.2000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 1.508333 $37.7100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 202 231 393.581742 $19679.0800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 3.966666 $198.3300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.633333 $65.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 122 127 213.659519 $10682.9600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.633333 $90.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 21.433334 $1071.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.566667 $14.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 194 203 323.504755 $16175.2100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 12.852381 $321.3100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 39.428572 $1971.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 182 187 1102.265870 $55113.3000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 25 213.285715 $10664.2900 $50.0000
INTR -T1013 INTERPRETER 19 28 63.057989 $3152.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 247 521 1909.175318 $22910.1000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 70 73 465.092858 $33468.0700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 22.857142 $1644.8000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 39 42 302.986510 $21802.8900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.428571 $30.8400 $71.9600
PHY -97110HM PT SESSION BY PT ASST 3 3 12.857144 $740.0500 $57.5600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.432877 $49.7000 $114.8200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.261111 $59.9500 $229.6000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 3 3 2.082648 $37.7600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 70 448.457144 $32270.9700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 35.142856 $2528.8800 $71.9600
TRAV -TRAVS Travel by mile 300 653 110829.616317 $49319.1800 $0.4500
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Subtotal (Total Children Is Unduplicated) 340 2316 116554.950132 $592630.2700 $5.0800
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Total 2878 117316.621423 $641131.1100 $5.4600
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Number of Children (Unduplicated) With at Least One Authorization 438