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: 10-01-18 and 12-31-18 Date of Report: 02-05-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6490 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 53 53 72.239679 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 53 53 72.239679 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 29 23.001751 $1115.5800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.7100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $46.9800 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 3.533333 $83.7400 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.777778 $16.1400 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.266667 $48.7300 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 4.000000 $339.3600 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 11 11 7.800000 $398.3500 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $16.7000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.208219 $99.3700 $45.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 202 206 409.500000 $20475.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 4.766668 $357.5100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 14 18 20.250000 $1518.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 13 10.350001 $574.4300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 144 144 247.022146 $18526.6700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 11.000000 $825.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 8.000000 $600.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 408 409 667.505479 $37046.5600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 393 466 712.500000 $53437.5000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.087671 $157.6300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 6.000000 $306.3000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.224658 $62.5200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 1.041552 $15.6200 $15.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 2 4.000000 $204.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.087671 $106.5800 $51.0500
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Subtotal (Total Children Is Unduplicated) 770 1354 2165.423594 $136828.6700 $63.1900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 25 29 53.970395 $269852.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 2.688889 $134.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 12 12 8.072222 $403.6100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 7.714286 $552.4200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 13 14 23.122504 $5318.1500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 237 263 262.040061 $13102.0100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 7 9.733333 $243.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 104 115 233.847621 $11692.3900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 4.600000 $115.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 56.277781 $2813.9100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.366667 $59.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 53 55 95.455556 $4772.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 77 83 141.692065 $7084.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 6 6.366667 $159.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 802 836 5787.852466 $289392.6100 $50.0000
INTR -T1013 INTERPRETER 143 161 452.065723 $22603.3000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1059 1460 7878.938517 $78789.3700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 34 274.033333 $19576.9500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 81 85 620.785719 $44348.9200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 7 7 43.000000 $2457.8900 $57.1600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.833333 $95.0000 $114.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 3 3 2.716590 $48.9000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 106 112 869.847632 $62141.8800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 33.571428 $465.9700 $13.8800
TRAV -TRAVS Travel by mile 1126 1757 8410.191251 $3742.5400 $0.4500
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Subtotal (Total Children Is Unduplicated) 1171 5083 25282.784039 $840422.8000 $33.2400
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Total 6490 27520.447312 $977251.4700 $35.5100
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Number of Children (Unduplicated) With at Least One Authorization 1248