Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 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 7655 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 1 1 0.833333 $30.8300 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 62 62 226.945236 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 72 72 2393.709521 $88567.2600 $37.0000
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Subtotal (Total Children Is Unduplicated) 131 135 2621.488090 $88598.0900 $33.8000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 29 24.637823 $1194.9300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.466667 $26.3600 $56.4900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.222222 $5.2700 $23.7000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 10 11 9.722222 $824.8300 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 4 4 4.000000 $204.2800 $51.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.444444 $65.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.444444 $166.1100 $115.0000
EXIT -EXIT EXIT ASSESSMENT 221 223 445.000000 $22250.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 20 20 36.500000 $2737.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 31 45 81.005479 $6075.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 30 56.000000 $3108.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 145 145 262.000000 $19650.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 26 26 45.500000 $3412.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 24.000000 $1800.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 343 346 631.785714 $35064.1100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 281 333 595.071428 $44630.3600 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 3.161644 $161.4000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 5.285714 $269.8400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 8.000000 $408.4000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 12.279365 $184.1900 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 7.000000 $357.3500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 24 25 26.038356 $1329.2600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $133.6500 $44.5500
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Subtotal (Total Children Is Unduplicated) 757 1295 2298.565522 $144871.1800 $63.0300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 23 24.883105 $124415.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 10.787018 $539.3500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 3.714286 $265.9800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 16 16 18.331963 $4216.3400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 404 442 539.054972 $26952.7500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 45 47 55.527474 $1388.1900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 144 161 294.516662 $14725.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 5.600000 $140.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 53 79.322220 $3966.1000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.900000 $47.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 83 92 144.703174 $7235.1700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.566667 $89.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 110 120 209.863490 $10493.1700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 6.916667 $172.9200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 892 946 5896.976197 $294848.7800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 8 11.819047 $590.9600 $50.0000
INTR -T1013 INTERPRETER 157 188 592.934125 $29646.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1175 1765 8598.205313 $85982.0400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 51 53 376.866667 $26923.3800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.266667 $72.4600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 92 101 612.847617 $43781.8500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 32.480953 $1856.6100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.444444 $28.8900 $64.9900
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.222222 $25.3300 $113.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.222222 $1469.3200 $456.0000
SENS -V5264 EARMOLD 7 7 13.033246 $234.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 134 143 943.466664 $67401.2500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 7 20.999999 $1500.2400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 95.723811 $1328.6400 $13.8800
TRAV -TRAVS Travel by mile 1215 2007 8939.212815 $3977.9500 $0.4400
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Subtotal (Total Children Is Unduplicated) 1293 6225 27538.409707 $754316.9500 $27.3900
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Total 7655 32458.463319 $987786.2200 $30.4300
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Number of Children (Unduplicated) With at Least One Authorization 1381