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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2989 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 1 1 2.466667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 2.466667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 29 29 15.603956 $756.7900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.202740 $4.4700 $22.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.266667 $12.0900 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.613851 $71.0800 $115.8000
EXIT -EXIT EXIT ASSESSMENT 24 24 30.712264 $1535.6200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 90 94 156.285513 $11721.4400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 33 37 71.000000 $5325.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 41 41 79.500000 $5962.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 27 28 53.000000 $3975.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 99 120 208.071227 $11547.9700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 19 21 41.000000 $2275.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 26 29 48.500000 $3637.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 14 16 30.500000 $2287.5000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.144444 $7.4200 $51.3900
OCTH -97165 OT EVAL LOW COMPLEXITY 20 20 9.238811 $474.9600 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.227778 $11.7100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 22 23 9.027169 $464.0900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 13.595695 $698.9500 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.008219 $0.4200 $51.3000
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 10 2.671613 $137.3400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 1.967655 $101.1500 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.500000 $25.7100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 15 15 9.828985 $505.3000 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.052055 $2.6800 $51.4600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 15 16 8.429223 $433.3500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 0.191781 $9.8600 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 1.204186 $61.9100 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.126027 $6.4800 $51.4000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.030137 $1.5500 $51.3500
SPCH -92521 EVAL OF SPEECH FLUENCY 26 28 28.531246 $1466.7800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.422222 $21.7100 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.272222 $13.9900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 1.527777 $78.5400 $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 27 29 14.998477 $771.0700 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.427778 $73.4000 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.738888 $89.3900 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.128767 $6.6200 $51.4200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 19.714285 $1013.5100 $51.4100
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Subtotal (Total Children Is Unduplicated) 323 634 878.828325 $56667.9700 $64.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 33 34 57.629974 $288150.5000 $5000.0100
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.752740 $174.3400 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 47 49 54.486197 $2724.3300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 5 5 3.019445 $150.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.772222 $19.3100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 198 217 320.219047 $16010.9400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 0.700000 $35.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 104 109 161.933334 $8096.6700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.400000 $20.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.066667 $26.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 22.000000 $1100.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 184 193 275.766669 $13788.3500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.433333 $121.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.466666 $61.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 37.023809 $1851.2000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 184 192 1168.933343 $58446.6100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 21 21 112.785717 $5639.2800 $50.0000
INTR -T1013 INTERPRETER 14 21 29.343704 $1467.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 277 546 1897.111049 $22765.3100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 71 73 425.928576 $30649.8100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 17.428572 $1254.1500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 52 52 354.903181 $25538.8000 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 3.000000 $1377.6600 $459.2200
SENS -V5264 EARMOLD 3 3 3.252663 $58.9700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 70 76 530.376196 $38165.8300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 16.285714 $1171.9200 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 3.428571 $47.8600 $13.9600
TRAV -TRAVS Travel by mile 354 719 107895.804433 $48013.6300 $0.4500
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Subtotal (Total Children Is Unduplicated) 416 2354 113401.251822 $567227.5700 $5.0000
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Total 2989 114282.546814 $623895.5500 $5.4600
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Number of Children (Unduplicated) With at Least One Authorization 467