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 4299 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 49 50 88.857141 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 14.285714 $528.5700 $37.0000
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Subtotal (Total Children Is Unduplicated) 50 51 103.142855 $528.5700 $5.1200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 36 36 35.089498 $1701.8400 $48.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.238356 $2.1600 $9.0800
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.238356 $20.2300 $84.8600
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.238356 $12.1800 $51.0800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.238356 $5.3400 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.238356 $10.7300 $45.0100
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 -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 3.000000 $153.1500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 289 361 668.781278 $37887.5700 $56.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 5 1.718036 $8590.0000 $4999.9000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.238356 $161.9200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 6.142857 $1412.8700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 306 359 426.221026 $21311.0400 $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 152 166 375.631740 $18781.5700 $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 60 64 148.276189 $7413.8100 $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 68 70 139.377778 $6968.8900 $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 124 126 268.510320 $13425.5300 $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 61 63 454.380948 $22719.0400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.466667 $123.3400 $50.0000
INTR -T1013 INTERPRETER 125 148 418.050814 $20902.5500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 946 1353 7471.075335 $74710.8000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 22.266665 $1590.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.866667 $221.1800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 9 9 54.095237 $3864.5700 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.000000 $571.5200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 20 132.333332 $9453.9100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.133333 $152.4000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 14.652381 $203.3800 $13.8800
TRAV -TRAVS Travel by mile 948 1357 7447.118192 $3313.9700 $0.4400
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Subtotal (Total Children Is Unduplicated) 1027 3887 17548.909037 $221019.7800 $12.5900
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Total 4299 18320.833170 $259435.9200 $14.1600
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Number of Children (Unduplicated) With at Least One Authorization 1075