Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 5409 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
CASE -CASE NON-TCM CASE MANAGEMENT 2 2 0.688889 $25.4900 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 53 55 164.535715 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 65 65 1308.219048 $48404.1300 $37.0000
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Subtotal (Total Children Is Unduplicated) 117 122 1473.443652 $48429.6100 $32.8700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 30 25.331431 $1228.5800 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.788889 $18.7000 $23.7000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 2 4.000000 $153.8800 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.577778 $71.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.577778 $181.4500 $115.0000
EXIT -EXIT EXIT ASSESSMENT 212 214 427.000000 $21350.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 6 10.000000 $750.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 12 12 21.500000 $1612.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $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 37 37 71.500000 $3968.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 31 34 62.000000 $4650.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.788889 $11.8300 $15.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 4 5.000000 $255.2500 $51.0500
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Subtotal (Total Children Is Unduplicated) 290 350 643.064765 $35089.4300 $54.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.000000 $20000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 4.000000 $200.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.788889 $871.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 390 428 511.413648 $25570.6900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 47 49 57.644141 $1441.1100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 130 142 235.445235 $11772.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 6.866667 $171.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 53 78.938887 $3946.9400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 78 108.223019 $5411.1600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 42.000000 $1050.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 99 107 156.996028 $7849.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 13.066667 $326.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 64 70 399.957146 $19997.8600 $50.0000
INTR -T1013 INTERPRETER 157 181 532.630955 $26631.5600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1127 1770 7988.175157 $79881.7400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 5.800000 $414.3500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 7 21.466667 $1533.5700 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.577778 $102.5600 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.788889 $89.9300 $114.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.788889 $359.7400 $456.0100
SENS -V5264 EARMOLD 1 1 1.577778 $28.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 36.552382 $2611.3000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 4 23.428572 $325.1900 $13.8800
TRAV -TRAVS Travel by mile 1268 2015 8331.892183 $3707.6900 $0.4400
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Subtotal (Total Children Is Unduplicated) 1345 4937 18567.019577 $214295.5700 $11.5400
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Total 5409 20683.527994 $297814.6100 $14.4000
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Number of Children (Unduplicated) With at Least One Authorization 1401