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 5376 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 50 53 151.875394 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 48 49 1363.120637 $50435.4600 $37.0000
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Subtotal (Total Children Is Unduplicated) 91 102 1514.996031 $50435.4600 $33.2900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 21 14.029527 $680.4300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.005556 $0.1100 $19.8700
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.005556 $0.1300 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.005556 $0.0800 $13.9800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.105556 $2.5000 $23.7100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.005556 $0.0500 $9.1400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.005556 $0.1600 $28.0400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.005556 $0.2200 $38.7700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 7 7 1.977778 $101.0100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.005556 $0.0900 $16.8300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.005556 $0.1300 $22.5700
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.200000 $54.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.200000 $23.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 266 271 532.750000 $26637.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 3 2.407143 $133.5900 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 18.500000 $1387.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 39 39 68.500000 $3801.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 24 27 48.000000 $3600.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.183562 $60.4200 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.957143 $14.3600 $15.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 336 400 695.355157 $36847.5100 $52.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.000000 $15000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.911111 $45.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 9.561904 $478.1000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.428571 $102.3000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.132877 $490.5700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 301 338 385.982133 $19299.1100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 8 6.750000 $168.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 132 149 300.435723 $15021.8300 $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 62 63 99.136508 $4956.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.566667 $39.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 92 95 150.633332 $7531.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.133334 $53.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 66 70 424.061906 $21203.1200 $50.0000
INTR -T1013 INTERPRETER 127 142 415.644588 $20782.2300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1145 1782 8634.012048 $86340.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 8 46.228572 $3302.5600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 14 57.504761 $4108.1400 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.232877 $15.1400 $65.0100
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.165753 $18.9000 $114.0300
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 0.132877 $60.6000 $456.0800
SENS -V5264 EARMOLD 2 2 0.333333 $6.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 21 111.571426 $7970.6800 $71.4400
TRAV -TRAVS Travel by mile 1315 2109 9055.905266 $4029.8800 $0.4400
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Subtotal (Total Children Is Unduplicated) 1367 4874 19806.409219 $215751.3400 $10.8900
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Total 5376 22016.760407 $303034.3200 $13.7600
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Number of Children (Unduplicated) With at Least One Authorization 1408