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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2350 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 3 3 3.766667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 3.766667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 30 16.409969 $795.8900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.666667 $10.5600 $15.8400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.166667 $2.4500 $14.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.250000 $11.3300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.250000 $144.7600 $115.8100
EXIT -EXIT COS Exit 5 5 3.616667 $180.8400 $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 87 101 172.999798 $9601.5000 $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 0.276256 $14.2000 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 29 31 23.003567 $1182.6200 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 6 6 7.116667 $365.8700 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 15.380051 $790.6900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 13.466927 $692.3400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.115068 $5.9200 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 2.199619 $113.0800 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 1.122071 $57.6900 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.150685 $7.7500 $51.4200
PSTH -97161 PT EVAL LOW COMPLEXITY 21 21 11.045130 $567.8400 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 3.966667 $203.9300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 10 10 2.197565 $112.9800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 45 46 31.408429 $1614.7200 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 4 3.416667 $175.6500 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.416438 $21.4100 $51.4200
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 0.186302 $9.5800 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.115068 $5.9200 $51.4200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 6.166667 $317.0300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.172222 $8.8500 $51.4000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.288356 $66.2400 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 0.161644 $8.3100 $51.4300
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 3 18.857142 $969.4500 $51.4100
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Subtotal (Total Children Is Unduplicated) 258 566 787.010050 $50291.9100 $63.9000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 28 58.591477 $292957.0000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.666667 $46.2400 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.866667 $129.4600 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.666667 $154.4200 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 59 62 58.446373 $2922.3300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 10 11.263889 $563.2000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 4.574999 $114.3700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 179 199 365.852373 $18292.5800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.633333 $31.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 120 120 204.495232 $10224.7400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 2.366666 $118.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.533333 $138.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 16.176516 $808.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.466667 $11.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 167 168 314.631739 $15731.5500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.100000 $77.5000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.857143 $492.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 168 174 1188.323830 $59416.1300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 26 26 175.428577 $8771.4100 $50.0000
INTR -T1013 INTERPRETER 19 30 63.057989 $3152.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 154 301 1355.181681 $16262.1600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 72 74 513.757153 $36969.9100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 51.428571 $3700.8100 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.857143 $277.5600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 37 37 245.571434 $17671.2900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 35.571429 $2559.7200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 5 48.714287 $2803.9900 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.250000 $516.6200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.666667 $306.1600 $459.2400
SENS -V5264 EARMOLD 3 3 1.273516 $23.0900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 74 472.142869 $33975.3400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 38.571428 $2775.6100 $71.9600
TRAV -TRAVS Travel by mile 183 424 81058.363928 $36070.9700 $0.4500
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Subtotal (Total Children Is Unduplicated) 287 1781 86315.350243 $568118.6900 $6.5800
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Total 2350 87106.126960 $618410.6000 $7.1000
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Number of Children (Unduplicated) With at Least One Authorization 331