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: 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 3066 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 37 37 25.585409 $1240.8900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 7.285714 $408.7300 $56.1000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 7.285714 $172.4500 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 2.306393 $33.8600 $14.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.744444 $33.7400 $45.3200
EXIT -EXIT EXIT ASSESSMENT 19 19 18.569407 $928.4700 $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 98 120 208.071227 $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 24 27 44.500000 $3337.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 14 16 30.500000 $2287.5000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.527778 $27.1300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 21 21 8.897563 $457.4200 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.394444 $20.2800 $51.4000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 6.278463 $322.7700 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 12.650881 $650.3800 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 1.142466 $58.7400 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.241096 $12.4000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 9 2.720243 $139.8500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 6 6 3.514992 $180.7000 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 15 15 11.301772 $581.0300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 10 10 3.824201 $196.6000 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.068493 $3.5200 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.538660 $27.6900 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 27 28 15.311902 $787.1900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.394444 $20.2800 $51.4000
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.106849 $5.4900 $51.3900
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.142466 $7.3300 $51.4200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 7.275190 $374.0200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 4.142857 $212.9900 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 2.100228 $107.9700 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.120548 $6.1900 $51.3900
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 19.285715 $991.4800 $51.4100
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Subtotal (Total Children Is Unduplicated) 281 591 858.615072 $55302.9800 $64.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 38 38 64.199271 $320995.5000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.966666 $223.8800 $231.6000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 48 50 59.449292 $2972.4800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 5 5 3.019445 $150.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.750000 $18.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 201 223 368.211903 $18410.5900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 1.366667 $68.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 124 126 195.249202 $9762.4500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 1.033333 $51.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.966667 $49.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 30.133334 $1506.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.500000 $62.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 194 200 322.910317 $16145.5200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 7.466667 $186.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 8 8 36.714286 $1835.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 173 174 1162.470625 $58123.5800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 36 36 207.999995 $10400.0200 $50.0000
INTR -T1013 INTERPRETER 11 20 44.057988 $2202.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 254 586 2210.089585 $26521.0900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 67 68 452.420633 $32556.2000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 9.000000 $647.6400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 43 43 325.387299 $23414.8800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 1.428571 $82.2300 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 59 371.285711 $26717.7500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 6.428571 $462.6000 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 9.571429 $133.6200 $13.9600
TRAV -TRAVS Travel by mile 312 801 129568.675889 $57658.0600 $0.4500
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Subtotal (Total Children Is Unduplicated) 338 2475 135469.753346 $611728.5300 $4.5200
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Total 3066 136328.368418 $667031.5100 $4.8900
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Number of Children (Unduplicated) With at Least One Authorization 377