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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6620 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 0.166667 $6.1700 $37.0100
SCONLY-SCONLY *SERVICE COORDINATION ONLY 79 82 315.634921 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 552 553 11051.938117 $408921.7400 $37.0000
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Subtotal (Total Children Is Unduplicated) 606 636 11367.739705 $408927.9100 $35.9700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 31 25.189041 $1221.6600 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.038889 $0.7700 $19.7200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.038889 $0.9100 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.038889 $0.5400 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.038889 $0.9200 $23.7100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.052588 $0.4800 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.038889 $1.0800 $27.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.038889 $1.5000 $38.4800
AUDE -92585 AUD EVOKED RESPONSE (COMP) 12 12 10.135921 $859.9300 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 4 4 3.013699 $153.9100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.038889 $0.6500 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.052588 $1.1800 $22.4100
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.052588 $47.3700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 116 116 232.000000 $11600.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 9.000000 $675.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 10 19.000000 $1425.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 10.000000 $555.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 38 38 69.000000 $5175.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 11 12 22.000000 $1650.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 17.500000 $1312.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 198 200 376.500000 $20895.7500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 262 358 681.000000 $51075.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 7.000000 $357.3500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 12.000000 $612.6000 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 3.333333 $50.0000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 8.000000 $408.4000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 17 17.054795 $870.6500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 9.000000 $400.9500 $44.5500
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Subtotal (Total Children Is Unduplicated) 516 884 1577.156776 $102247.6900 $64.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 26 28.378614 $141892.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.033333 $1.6700 $49.9500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 11 11 8.559589 $427.9800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 15 15 16.729529 $3847.8100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 269 322 415.909295 $20795.4700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 4 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 175 196 184.733267 $4618.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 121 140 257.253970 $12862.7100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 5 6.133333 $153.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 56 83.100000 $4155.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.033333 $25.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 67 68 111.466666 $5573.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 117 127 200.570635 $10028.5400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 802 876 5086.390456 $254319.5100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 30.580952 $1529.0600 $50.0000
INTR -T1013 INTERPRETER 85 97 280.700794 $14035.0400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 989 1424 6977.808711 $69778.0900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 53 305.590476 $21831.3900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 77 83 476.857143 $34066.6500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.714286 $408.2300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 9.004762 $514.7100 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.285714 $377.6100 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 4.000000 $1824.0000 $456.0000
SENS -V5264 EARMOLD 4 4 3.588585 $64.5900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 140 152 861.220631 $61525.5800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 24.428571 $1745.1800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 33.857143 $469.9400 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 10.285714 $380.5700 $37.0000
TRAV -TRAVS Travel by mile 986 1417 6956.027758 $3095.4300 $0.4400
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Subtotal (Total Children Is Unduplicated) 1094 5100 22389.243260 $670548.0600 $29.9500
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Total 6620 35334.139741 $1181723.6600 $33.4400
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Number of Children (Unduplicated) With at Least One Authorization 1433