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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 8456 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 61 123.444445 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 790 822 19720.590483 $729661.9700 $37.0000
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Subtotal (Total Children Is Unduplicated) 804 883 19844.034928 $729661.9700 $36.7700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 25 16.580517 $804.1600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.688889 $38.9200 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.016667 $20.0400 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.016667 $23.8800 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.016667 $14.1000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 2.016667 $47.8000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.046804 $9.5000 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.450000 $4.4800 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.016667 $28.2900 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 3.016667 $116.0500 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 18 18 15.235692 $1292.5900 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 11 11 7.707915 $393.6400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.016667 $16.9800 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 1.457915 $32.6600 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 210 213 423.750000 $21187.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 14 26.000000 $1950.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 35 52 100.500000 $7537.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 19.500000 $1082.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 216 216 396.505479 $29737.9100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 21 21 35.000000 $2625.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 34 34 59.500000 $4462.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 474 482 890.434050 $49419.0900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 349 414 776.928571 $58269.6500 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 4.008219 $204.6200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 8.000000 $408.4000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.000000 $204.2000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 6.000000 $306.3000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 4.257534 $217.3500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $97.8800 $48.9400
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Subtotal (Total Children Is Unduplicated) 891 1574 2821.668254 $181313.4900 $64.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 24 23.891932 $119459.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 0.561111 $28.0600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 10 12.291270 $614.5700 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.450000 $32.2200 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.216667 $87.1300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 35 35 40.100000 $9223.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 301 329 455.110494 $22755.5500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 9.250000 $231.2500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 135 150 237.426189 $11871.3100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 3.200000 $80.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 47 62.872220 $3143.6000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.100000 $2.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 73 79 100.600001 $5030.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 100 108 142.139681 $7106.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.100000 $27.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 895 952 5710.226945 $285511.3800 $50.0000
INTR -T1013 INTERPRETER 178 187 499.983331 $24999.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1145 1700 7821.948948 $78219.5000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 53 308.042853 $22006.6000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.142857 $637.3700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 87 93 484.276097 $34596.6900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 26.857144 $1535.1500 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -V5264 EARMOLD 2 2 2.766667 $49.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 128 138 747.611894 $53409.4300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 55.857143 $775.3000 $13.8800
TRAV -TRAVS Travel by mile 1342 2056 8302.070735 $3694.4200 $0.4400
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Subtotal (Total Children Is Unduplicated) 1443 5999 25062.094179 $685127.9600 $27.3400
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Total 8456 47727.797361 $1596103.4300 $33.4400
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Number of Children (Unduplicated) With at Least One Authorization 1782