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 1152 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
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.288889 $5.6900 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.288889 $100.7500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 4.288889 $59.4900 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 2.288889 $54.2500 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 3.061111 $27.7900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 3.061111 $85.1900 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 3.288889 $126.5200 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 4 4 18.571429 $1575.6000 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $102.1400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 4.061111 $67.8200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.288889 $51.2700 $22.4000
EXIT -EXIT EXIT ASSESSMENT 101 101 163.625637 $8181.2700 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 4.328766 $240.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 0.076712 $5.7500 $74.9900
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 3.000000 $153.1500 $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 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.477778 $75.4400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 4.872222 $248.7300 $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) 129 169 230.869211 $11460.9000 $49.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.016667 $83.5000 $5009.9000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 6.000000 $1380.0000 $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 -T1027SC EI INDIVIDUAL SESSION BY EI PROF 136 141 1213.747614 $60687.3900 $50.0000
INTR -T1013 INTERPRETER 2 3 4.285714 $214.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 9 77.285713 $5521.2900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 58.714286 $4194.5500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 14 122.390474 $8743.5800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.428571 $173.5000 $71.4400
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Subtotal (Total Children Is Unduplicated) 393 963 3057.374208 $158319.2600 $51.7800
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Total 1152 3302.862862 $169785.6000 $51.4100
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Number of Children (Unduplicated) With at Least One Authorization 480