Summary Report for FSPSAs Initiated During the Report Period Center: 09
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 1930 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.966667 $72.7700 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 34 34 69.498411 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 35 35 71.465078 $72.7700 $1.0200
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.166667 $3.2900 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.727778 $17.1000 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 0.894445 $12.4100 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 0.894445 $8.1200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 0.894445 $24.8900 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 0.894445 $75.8900 $84.8500
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.477778 $24.4000 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.416667 $6.9600 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.250000 $5.6000 $22.4000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 4.285714 $321.4300 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 3 4.400000 $220.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 23 14.302384 $720.0800 $50.3500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 141 194 273.300270 $13665.0300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 157 213 212.330902 $5308.2700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 50 52 54.888095 $2744.4000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 1.400000 $35.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 46 46 43.879604 $2193.9800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 25 19.955554 $997.7700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 55 48.518078 $2425.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 5.400000 $135.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 588 644 4358.276159 $217913.9000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 24.428571 $1221.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 130 150 869.353960 $62106.6700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 13.409524 $957.9800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 123 133 883.514272 $63118.3000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.200000 $157.1700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.285714 $130.6500 $57.1600
SENS -V5264 EARMOLD 2 2 0.644445 $11.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 312 341 2365.252362 $168973.7000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 9.714286 $693.9800 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 914 1872 9190.751796 $542840.7200 $59.0600
-------------------------------------------------------------------------------------------------------------------------------------
Total 1930 9276.519258 $543633.5700 $58.6000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 947