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: 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 5434 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 2 2 1.377778 $50.9800 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 63 65 126.841271 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 77 77 2067.123810 $76483.5400 $37.0000
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Subtotal (Total Children Is Unduplicated) 135 144 2195.342859 $76534.5200 $34.8600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 28 18.417123 $893.2200 $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 0.227778 $5.4000 $23.7000
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 -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 1 1 0.444444 $20.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.444444 $51.1100 $114.9900
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 -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.222222 $3.3300 $15.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 342 398 696.457602 $36902.1100 $52.9900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 3.000000 $150.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.222222 $741.1100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 304 337 471.802019 $23590.1100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 10 9.066667 $226.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 127 138 237.103178 $11855.1800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 3.750000 $93.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 40 41 62.109522 $3105.4700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.866667 $21.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 66 103.911111 $5195.5600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 47.500000 $1187.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 92 95 141.203175 $7060.1600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.266667 $106.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 49 53 276.095243 $13804.7800 $50.0000
INTR -T1013 INTERPRETER 131 156 431.382687 $21569.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1237 1804 7871.058239 $78710.5600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 31.752382 $2268.3800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 12 15 58.257144 $4161.8900 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.444444 $28.8900 $64.9900
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.222222 $25.3300 $113.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.222222 $101.3200 $455.9500
SENS -V5264 EARMOLD 1 1 0.444444 $8.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 15 91.123810 $6509.8900 $71.4400
TRAV -TRAVS Travel by mile 1283 2132 8307.737168 $3696.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 1316 4892 18158.541233 $194218.9600 $10.7000
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Total 5434 21050.341694 $307655.6000 $14.6200
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Number of Children (Unduplicated) With at Least One Authorization 1352