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 4187 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 61 63 107.600795 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 104.571429 $3869.1400 $37.0000
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Subtotal (Total Children Is Unduplicated) 64 66 212.172224 $3869.1400 $18.2400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 32 23.180365 $1124.2500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.044444 $0.8800 $19.6900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.044444 $1.0400 $23.4700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.044444 $0.6200 $13.8600
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.044444 $1.0500 $23.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.058143 $0.5300 $9.0700
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.044444 $1.2400 $27.8000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.044444 $1.7100 $38.4300
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 0.044444 $0.7400 $16.6800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.044444 $0.9900 $22.3800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.058143 $2.6100 $44.9700
EXIT -EXIT EXIT ASSESSMENT 186 190 380.000000 $19000.0000 $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 3 3 6.000000 $450.0000 $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 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $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 4 4 7.500000 $416.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 22 22 43.500000 $3262.5000 $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 11 11 21.500000 $1612.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 36 38 74.000000 $4107.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 32 36 71.500000 $5362.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 4.000000 $204.2000 $51.0500
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Subtotal (Total Children Is Unduplicated) 282 364 653.179601 $37125.9700 $56.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.127778 $10639.0000 $5000.0500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.058143 $2.9100 $49.9600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 304 355 417.148804 $20857.4300 $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 143 161 279.919048 $13995.9600 $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 60 67 113.911108 $5695.5400 $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 122 128 206.246028 $10312.2900 $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 -T1027SC EI INDIVIDUAL SESSION BY EI PROF 50 55 321.661904 $16083.1100 $50.0000
INTR -T1013 INTERPRETER 129 151 397.522246 $19876.1300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 850 1319 6204.517494 $62045.1700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 38.533331 $2752.8300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 8.285714 $591.9300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 6 31.942857 $2282.0000 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 9.142857 $653.1700 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 18 89.552380 $6397.6300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.142857 $224.5300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.142857 $1.9800 $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) 983 3757 14505.296169 $182978.5200 $12.6100
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Total 4187 15370.647994 $223973.6300 $14.5700
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Number of Children (Unduplicated) With at Least One Authorization 1071