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: 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 5765 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 5.377778 $198.9800 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 57 59 264.400794 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 17 17 385.623809 $14268.0800 $37.0000
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Subtotal (Total Children Is Unduplicated) 75 78 655.402381 $14467.0600 $22.0700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 34 31.585847 $1531.9200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 3.266667 $184.5400 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 2.466667 $48.6200 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.466667 $57.9400 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 2.466667 $34.2100 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 3.400000 $80.5800 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 2.702283 $24.5400 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.466667 $40.8200 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 2.466667 $94.8900 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 4 4 2.602283 $220.7800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 2.235616 $114.1700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 2.466667 $41.1900 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 2.702283 $60.5300 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.702283 $76.6000 $45.0000
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 36 36 65.500000 $4912.5000 $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 10 11 20.000000 $1500.0000 $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 194 196 369.000000 $20479.5000 $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 259 355 675.000000 $50625.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 3.273973 $167.1300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 5.285714 $269.8400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 6.000000 $306.3000 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.347945 $20.2200 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 2.000000 $102.1000 $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 13 14 11.087672 $566.0300 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 4.000000 $178.2000 $44.5500
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Subtotal (Total Children Is Unduplicated) 498 878 1555.992568 $99982.1500 $64.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 28 30.438966 $152195.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 7 4.455784 $222.7900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 16.491325 $3793.0200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 264 317 412.320407 $20616.0300 $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 174 195 183.233267 $4580.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 153 169 322.965873 $16148.2900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 9 13.900000 $347.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 66 114.844447 $5742.2400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 12.342858 $308.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 66 71 113.852379 $5692.6100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 8.776190 $219.4100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 124 134 235.153970 $11757.7100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 8.333334 $208.3400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 12.000000 $600.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 713 763 4804.541252 $240227.1200 $50.0000
INTR -T1013 INTERPRETER 80 93 261.924604 $13096.2300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 890 1304 6884.807922 $68848.0900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 60 63 432.509524 $30898.4600 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 7.000000 $500.0800 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.900000 $135.7400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 80 85 550.481746 $39326.4400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.714286 $408.2300 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 5 6 24.999999 $1786.0000 $71.4400
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.224658 $25.6200 $114.0200
SENS -V5264 EARMOLD 3 3 4.940640 $88.9300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 133 142 860.857143 $61499.6500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 32.666667 $2333.7100 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 8.866667 $633.4400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 17.714286 $1265.5100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 42.142857 $584.9400 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 2 2 19.285714 $713.5700 $37.0000
TRAV -TRAVS Travel by mile 891 1300 6847.036495 $3046.9300 $0.4500
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Subtotal (Total Children Is Unduplicated) 961 4809 22300.723260 $688051.0300 $30.8500
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Total 5765 24512.118209 $802500.2300 $32.7400
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Number of Children (Unduplicated) With at Least One Authorization 1085