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: 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 6361 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 58 59 97.807140 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 249.666668 $9237.6700 $37.0000
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Subtotal (Total Children Is Unduplicated) 67 68 347.473808 $9237.6700 $26.5900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 38 38 37.089498 $1798.8400 $48.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.238356 $2.1600 $9.0800
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 2.238356 $189.9100 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 3.381213 $172.6800 $51.0700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.238356 $5.3400 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.138356 $141.2300 $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 29 29 55.500000 $4162.5000 $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 -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.175342 $8.9500 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.057534 $2.9400 $51.0200
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 10.714285 $546.9700 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.216438 $18.2500 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92521TLGT 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 -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 16 14.509589 $740.7200 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.169864 $110.7700 $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) 789 1390 2597.443378 $169327.1800 $65.1900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 30 34.374657 $171873.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 10.154794 $507.7400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 15.345597 $3529.4900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 314 371 443.971026 $22198.5400 $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 60 66 58.329453 $1458.2400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 154 168 379.798407 $18989.9000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 13 13 23.483334 $1174.1700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 10 10 9.200000 $230.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 65 150.442856 $7522.1400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 5 5 9.833333 $491.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 17.504763 $437.6200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 70 72 143.277778 $7163.8900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 5 5 5.166666 $258.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.766667 $19.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 125 127 271.410320 $13570.5300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 9 15.699999 $785.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 7.833334 $195.8400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 695 734 5042.404709 $252120.3600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 19 100.666666 $5033.3500 $50.0000
INTR -T1013 INTERPRETER 144 170 468.536528 $23426.8400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 946 1353 7471.075335 $74710.8000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 45 51 363.840475 $25992.7700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 15.295238 $874.8900 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 17.600000 $1257.3400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 9.142857 $653.1700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 79 81 546.685710 $39055.2500 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.000000 $571.5200 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 4 4 12.999999 $928.7200 $71.4400
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.202740 $23.1100 $113.9800
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 3 3 6.308219 $113.5500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 115 122 827.876183 $59143.5200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 24.847619 $1775.1100 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 8.285714 $591.9300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 9 9 62.180952 $4442.2100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 39.938094 $554.3400 $13.8800
TRAV -TRAVS Travel by mile 948 1357 7447.118192 $3313.9700 $0.4400
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Subtotal (Total Children Is Unduplicated) 1042 4903 24073.133829 $745976.7700 $30.9900
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Total 6361 27018.051015 $924541.6100 $34.2200
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Number of Children (Unduplicated) With at Least One Authorization 1194