Summary Report for FSPSAs Ending During the Report Period Center: 01
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end 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 ending between: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 8552 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 61 64 158.799998 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 630 650 18701.117461 $691941.4000 $37.0000
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Subtotal (Total Children Is Unduplicated) 639 714 18859.917459 $691941.4000 $36.6900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 25 18.029527 $874.4300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.005556 $19.8200 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.005556 $23.6200 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 2.005556 $27.8200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 4 1.805556 $42.7900 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.005556 $9.1300 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.005556 $27.9900 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.005556 $38.6900 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 4.155555 $352.5500 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 18 18 9.377778 $478.9200 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 2.294445 $38.3200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.005556 $22.5300 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 4.600000 $207.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 3.133333 $360.3300 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 269 274 538.750000 $26937.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 7.000000 $525.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 15 15 27.000000 $2025.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 36 57 69.366666 $5202.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 19 25 41.457143 $2300.8700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 197 199 336.500000 $25237.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 19 19 34.000000 $2550.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 31 31 55.000000 $4125.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 444 455 809.000000 $44899.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 347 434 747.000000 $56025.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 10 14.318981 $730.9900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 7.000000 $357.3500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 10.428571 $532.3800 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 4 3.623810 $54.3600 $15.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 4.000000 $204.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 7.783561 $397.3500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 4.000000 $195.7600 $48.9400
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Subtotal (Total Children Is Unduplicated) 935 1641 2781.663818 $175633.6400 $63.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 24 32.985692 $164928.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.911111 $95.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 12.539682 $626.9900 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.428571 $102.3000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 26 27 32.159600 $7396.7100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 311 353 402.624990 $20131.2600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 8 6.750000 $168.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 152 304.235723 $15211.8300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 4.816667 $120.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 46 92.126985 $4606.3500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 63 64 100.136508 $5006.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.566667 $39.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 97 154.533332 $7726.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.133334 $53.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 905 997 6246.496806 $312324.9800 $50.0000
INTR -T1013 INTERPRETER 157 177 492.144588 $24607.2300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1145 1784 8645.716810 $86457.1800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 50 384.438096 $27464.2400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 7.228571 $413.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 94 102 504.861111 $36067.2600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 8 9 50.831746 $2905.5500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 3 1.632877 $106.1400 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 3 0.865753 $98.7000 $114.0100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 5 6 4.766210 $2173.3900 $456.0000
SENS -V5264 EARMOLD 7 8 8.326027 $149.8700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 136 149 874.602372 $62481.6200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 30.714286 $426.3100 $13.8800
TRAV -TRAVS Travel by mile 1315 2111 9071.905266 $4037.0000 $0.4400
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Subtotal (Total Children Is Unduplicated) 1395 6197 27474.479381 $785927.0700 $28.6100
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Total 8552 49116.060658 $1653502.1100 $33.6700
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Number of Children (Unduplicated) With at Least One Authorization 1744