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 4309 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 69 71 288.360317 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 51 51 1190.050796 $44031.8800 $37.0000
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Subtotal (Total Children Is Unduplicated) 118 123 1478.577780 $44038.0500 $29.7800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 28 22.189041 $1076.1600 $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) 1 1 0.013699 $1.1600 $84.8500
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.013699 $0.7000 $51.0800
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 2 2 0.052588 $2.3700 $45.0100
EXIT -EXIT EXIT ASSESSMENT 116 116 232.000000 $11600.0000 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $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 6 6 11.500000 $862.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $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 1.500000 $112.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 16 17 32.000000 $1776.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 30 57.000000 $4275.0000 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 173 221 369.646426 $20530.6700 $55.5400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 6.216438 $31082.0000 $4999.9700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 5.763699 $288.1900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $460.0000 $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 174 195 184.233267 $4605.8300 $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 51 55 80.700000 $4035.0000 $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 71 75 447.757138 $22387.8800 $50.0000
INTR -T1013 INTERPRETER 80 90 263.200794 $13160.0400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 989 1422 6962.522997 $69625.2300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 21.142857 $1510.4500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 9 72.428571 $5174.3100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 17 106.276191 $7592.3700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 13.285714 $949.1400 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 10.285714 $380.5700 $37.0000
TRAV -TRAVS Travel by mile 986 1414 6938.170615 $3087.4800 $0.4400
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Subtotal (Total Children Is Unduplicated) 1080 3965 16110.351227 $213977.6900 $13.2800
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Total 4309 17958.575433 $278546.4100 $15.5100
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Number of Children (Unduplicated) With at Least One Authorization 1153