Summary Report for FSPSAs Initiated During the Report Period Center: 07
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 2195 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 19 19 14.472221 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.147222 $5.4500 $36.9900
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Subtotal (Total Children Is Unduplicated) 20 20 14.619443 $5.4500 $0.3700
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 4.000000 $225.9600 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 6 6 6.833333 $134.6800 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 18 18 22.038889 $517.6900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 17 17 20.833333 $288.9600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 17 17 19.377777 $459.2500 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 22 22 14.583334 $132.4200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 28 28 21.983334 $611.8000 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 12 12 15.833333 $609.1100 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 16 16 33.660317 $2855.7300 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 10 10 12.544444 $640.6400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 46 46 44.984921 $751.2500 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 21 21 22.105555 $495.1600 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 5.510198 $247.9600 $45.0000
EXIT -EXIT EXIT ASSESSMENT 101 101 163.625637 $8181.2700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.057534 $4.3200 $75.0900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 2.057534 $114.2000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 34 22.783557 $1264.5100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 26 27 8.783557 $658.7900 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 1.250000 $63.8100 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.488889 $24.9600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 8 14.798413 $755.4600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 38 39 35.191018 $1796.5000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 3.450000 $176.1200 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 10 12 9.966667 $508.8000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 12 13.236508 $675.7200 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 3.000000 $153.1500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 6.094444 $311.1200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 57 58 41.101901 $2098.2500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 4.022222 $205.3300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 5 5 4.133333 $211.0100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 8 8 14.396825 $641.3800 $44.5500
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Subtotal (Total Children Is Unduplicated) 311 561 612.726807 $27267.4100 $44.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.016667 $83.5000 $5009.9000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 39.428571 $1971.4300 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 7.452381 $533.6700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 30.215080 $6949.5000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 111 160 132.936319 $6646.8600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 27 35 18.094449 $452.3700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 231 253 646.242855 $32312.1400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.833333 $141.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 6 13.466668 $336.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 117 126 278.952380 $13947.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 4.066667 $101.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 60 122.028569 $6101.4300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.070834 $76.7700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 126 134 337.346429 $16867.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 13.466666 $336.6700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.400000 $70.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 556 588 4777.630646 $238881.5300 $50.0000
INTR -T1013 INTERPRETER 2 3 4.285714 $214.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 53 55 464.428566 $33178.7900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 6.857143 $489.8800 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.000000 $71.4400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 39 40 391.857142 $27994.2800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.714286 $622.5500 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 2 2 24.266667 $436.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 85 95 786.390465 $56179.7400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 23.857142 $1704.3600 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 3 10.571429 $755.2200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 6 40.366667 $2883.8000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 13 13 75.857142 $1052.9000 $13.8800
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Subtotal (Total Children Is Unduplicated) 653 1614 8270.100877 $452378.4400 $54.7000
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Total 2195 8897.447127 $479651.2900 $53.9100
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Number of Children (Unduplicated) With at Least One Authorization 738