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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 11754 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 5 5 26.319048 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 26.319048 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 94 128 133.892390 $6493.7900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 6 8 10.041878 $563.3500 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.322222 $6.2900 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 7.285714 $172.4500 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 12 8.092694 $118.8000 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.654795 $14.4500 $22.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 3 3.043378 $137.9200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 3.572832 $413.7800 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 15.142857 $757.1500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 82 84 102.239544 $5111.9700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 11 20.005479 $1500.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 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 9 9 15.005479 $832.8100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 381 388 683.743945 $51280.8800 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 164 171 329.010958 $24675.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 131 133 260.785714 $19558.9300 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 58 59 114.500000 $8587.5000 $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 472 519 919.059664 $51007.8700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 91 95 185.000000 $10267.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 112 115 218.500000 $16387.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 49 53 102.500000 $7687.5000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 6.100000 $305.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 8 5.811111 $298.7500 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 67 86 86.201219 $4431.6200 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 3 3 1.443683 $74.2200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 51 61 45.210424 $2324.2700 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 5 7 48.613307 $2499.2100 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 3 2.142466 $110.1500 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 3 5 24.880235 $1279.0900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 29 40 24.103578 $1239.1700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.433333 $22.2800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 3 1.238889 $63.6900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 12 19 14.421539 $741.4200 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.016667 $52.2700 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 46 61 73.089517 $3757.5400 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.501370 $25.7800 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 35 43 52.043694 $2675.5700 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 10 14 5.578083 $286.7600 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 21 23 14.712405 $756.3600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.498630 $25.6300 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.926484 $47.6300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 75 97 93.625648 $4813.3100 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 1.366666 $70.2600 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.672222 $34.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 5.672755 $291.6300 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.106849 $5.4900 $51.3900
SPCH -92522TL EVAL OF SPCH SOUND PROD 4 4 2.556165 $131.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 85 105 77.760426 $3997.6700 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 34.752478 $1786.6400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.316667 $16.2800 $51.4200
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.727778 $37.4200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 11 16 11.693303 $601.1500 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 4 2.127093 $109.3500 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 4 6 126.000000 $6477.6600 $51.4100
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Subtotal (Total Children Is Unduplicated) 959 2446 3916.744227 $246237.8800 $62.8700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 106 143 640.538291 $3202692.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.498630 $24.9300 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.358904 $94.2400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 6 9 15.114458 $3500.7700 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 147 170 268.830299 $13441.5200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 14 16 15.113097 $755.6600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 13.116667 $327.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 570 881 3753.776558 $187688.8800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 4 8.000000 $400.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 301 424 1702.509156 $85125.4800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 5 6 18.666667 $933.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 5 23.066667 $576.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 76 335.445242 $16772.2800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.500000 $62.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 538 756 3057.546398 $152877.3600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 4 5 18.733334 $936.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 7 29.066668 $726.6700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 27 31 453.195238 $22659.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 503 718 12226.351551 $611317.7400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 83 105 1574.285708 $78714.3000 $50.0000
INTR -T1013 INTERPRETER 60 126 413.640375 $20682.0200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 723 2150 20565.966384 $246791.6600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 193 273 4844.663484 $348622.0500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 75.428572 $5427.8400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 1 1 11.142857 $641.8300 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 139 194 3991.322210 $287215.5800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 27.571428 $1587.0200 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 3 4 3.506849 $805.2000 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 4 12.833333 $5893.3100 $459.2200
SENS -V5264 EARMOLD 5 6 10.578996 $191.8000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 228 296 5330.342843 $383571.5600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 8 11 181.571428 $13065.8800 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 2 35.571429 $496.5800 $13.9600
TRAV -TRAVS Travel by mile 903 2863 1129348.389696 $502560.0400 $0.4500
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Subtotal (Total Children Is Unduplicated) 970 9303 1189013.243417 $6197300.3700 $5.2100
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Total 11754 1192956.306692 $6443538.2500 $5.4000
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Number of Children (Unduplicated) With at Least One Authorization 1101