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 4055 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 49 50 239.440477 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 29.142857 $1078.2800 $37.0000
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Subtotal (Total Children Is Unduplicated) 53 54 273.961112 $1277.2600 $4.6600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 32 30.124736 $1461.0500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.466667 $9.2000 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.466667 $10.9600 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.466667 $6.4700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.466667 $11.0600 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.702283 $6.3800 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.466667 $12.9900 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.466667 $17.9500 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.235616 $19.9900 $84.8300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.235616 $12.0300 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.466667 $7.7900 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.702283 $15.7300 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.702283 $31.6000 $45.0000
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 15 16 30.000000 $1665.0000 $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 1 1 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
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Subtotal (Total Children Is Unduplicated) 174 224 380.969486 $20954.4700 $55.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.002283 $50.1200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $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 173 194 182.733267 $4568.3300 $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 123 133 233.587303 $11679.3800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 8.333334 $208.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 58 61 343.126986 $17156.3300 $50.0000
INTR -T1013 INTERPRETER 76 87 252.202382 $12610.1200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 890 1304 6884.807922 $68848.0900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 69.733334 $4981.7300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 7.000000 $500.0800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 43.428572 $3102.5300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 20 134.761906 $9627.3700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 10.523810 $751.8200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 4.285714 $59.4900 $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) 944 3777 16046.851176 $192408.8600 $11.9900
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Total 4055 16701.781774 $214640.5900 $12.8500
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Number of Children (Unduplicated) With at Least One Authorization 990