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: 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 2876 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 2.966667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.966667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 25 15.013003 $728.1300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.369863 $20.7500 $56.1100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 1.550685 $22.7600 $14.6800
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.501370 $58.0700 $115.8200
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 12.714286 $635.7200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 16 16 18.000000 $900.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 5.000000 $277.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 112 113 220.505479 $16537.9100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 45 45 89.500000 $6712.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 59 115.285714 $8646.4300 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 23 23 45.500000 $3412.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 127 139 270.791193 $15028.9100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 12 13 26.000000 $1443.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 34 68.000000 $5100.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 16 18 34.000000 $2550.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.700000 $35.9900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 16 18 18.035637 $927.2100 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.153425 $7.8900 $51.4000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 12 13 8.714765 $448.0300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.082192 $4.2300 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.082192 $4.2300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 14 14 4.980061 $256.0300 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.388889 $19.9900 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 12 12 6.688432 $343.8500 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 8 3.342845 $171.8500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 4 4 0.539727 $27.7500 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 2.950989 $151.7100 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 18 20 11.315526 $581.7400 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.016438 $52.2500 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 36 37 19.320701 $993.2900 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.142857 $58.7600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.183333 $9.4200 $51.4000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 1.844445 $82.7400 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.272222 $12.2100 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 7.857143 $415.8800 $52.9300
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Subtotal (Total Children Is Unduplicated) 340 662 1028.348968 $67832.3200 $65.9600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 29 36.534701 $182673.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.180822 $9.0400 $49.9900
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.197717 $509.0300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 35 32.472717 $1623.6300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 4 4 6.005556 $300.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.966667 $49.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 185 206 326.183687 $16309.1600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.300000 $15.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 88 145.782191 $7289.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.300000 $7.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 27.366665 $1368.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 165 171 274.288446 $13714.3800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.066667 $3.3400 $50.0200
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.133334 $78.3400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 16.857143 $842.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 165 169 1083.819058 $54190.9300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 20 122.071428 $6103.5800 $50.0000
INTR -T1013 INTERPRETER 31 53 118.785715 $5939.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 275 524 1906.881684 $19068.8100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 61 63 487.404763 $35073.6300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.714286 $501.9400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 42 45 314.142858 $22605.7200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 8.571429 $493.3700 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 2 2 0.509589 $117.0100 $229.6200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.033333 $933.7300 $459.2100
SENS -V5264 EARMOLD 2 2 1.010959 $18.3300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 79 83 579.571434 $41705.9500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 25.857143 $1860.6800 $71.9600
TRAV -TRAVS Travel by mile 347 680 105082.373515 $46761.6600 $0.4500
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Subtotal (Total Children Is Unduplicated) 412 2212 110615.383507 $460166.7500 $4.1600
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Total 2876 111646.699142 $527999.0700 $4.7300
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Number of Children (Unduplicated) With at Least One Authorization 480