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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6276 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 65 67 120.579366 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 23 23 647.241272 $23947.9200 $37.0000
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Subtotal (Total Children Is Unduplicated) 86 90 767.820638 $23947.9200 $31.1900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 34 36 26.319254 $1276.4900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 2.044444 $40.3000 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.044444 $48.0200 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 2.044444 $28.3600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 4.494444 $106.5200 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 2.058143 $18.6900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.044444 $29.0700 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 2.044444 $78.6500 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 4 4 2.480366 $210.4400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 2.013699 $102.8400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 2.044444 $34.1400 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.044444 $45.7900 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.224810 $55.1200 $45.0000
EXIT -EXIT EXIT ASSESSMENT 188 192 384.000000 $19200.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 30 30 56.500000 $4237.5000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 3.500000 $262.5000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 34 47 87.500000 $6562.5000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 21 24 47.500000 $2636.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 214 214 413.000000 $30975.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 16 16 32.000000 $2400.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 88 88 170.500000 $12787.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 5.000000 $375.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 323 327 625.642857 $34723.1800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 18.000000 $999.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 281 317 601.133334 $45085.0100 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 21.000000 $1575.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 4.320548 $220.5600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 12.714285 $649.0700 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.147945 $2.2200 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 17 12.499804 $638.1200 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.884150 $249.3300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 3.000000 $133.6500 $44.5500
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Subtotal (Total Children Is Unduplicated) 799 1425 2605.744747 $169304.8800 $64.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 27 27 20.882649 $104413.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 2.194978 $109.7500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 13.024658 $2995.6800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 312 367 434.898804 $21744.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 8 9 1.535615 $76.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 58 65 53.067809 $1326.7000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 145 163 283.385715 $14169.2900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.000000 $100.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 9 9 10.800000 $270.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 68 115.377775 $5768.8800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 19.609524 $490.2400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 61 97.340478 $4867.0300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 4 8.900000 $222.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 123 129 208.779361 $10438.9600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.388889 $69.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 7.633333 $190.8300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.142857 $57.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 664 711 4086.733354 $204336.6300 $50.0000
INTR -T1013 INTERPRETER 148 172 439.665103 $21983.2700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 850 1319 6204.517494 $62045.1700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 59 281.909526 $20139.6300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 8.285714 $591.9300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 8.571428 $612.3500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.266667 $233.3700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 76 79 457.071434 $32653.1900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.266667 $301.0400 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 3 3 19.714285 $1408.4000 $71.4400
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.024658 $2.8200 $114.1900
SENS -V5264 EARMOLD 2 2 0.240640 $4.3300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 134 826.847625 $59070.0300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 25.190476 $1799.6100 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 21.704762 $1550.5800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 19.714286 $1408.3900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 70.714286 $981.5200 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.571429 $77.3300 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 5.571429 $206.1400 $37.0000
TRAV -TRAVS Travel by mile 856 1320 6173.593686 $2747.2500 $0.4500
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Subtotal (Total Children Is Unduplicated) 1010 4761 19946.137394 $579464.6300 $29.0500
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Total 6276 23319.702779 $772717.4400 $33.1400
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Number of Children (Unduplicated) With at Least One Authorization 1460