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 5221 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 50 117.861905 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 70 72 1781.809527 $65926.9700 $37.0000
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Subtotal (Total Children Is Unduplicated) 119 122 1899.671432 $65926.9700 $34.7000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 22 13.380517 $648.9600 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.016667 $0.3300 $19.7500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.016667 $0.3900 $23.5400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.016667 $0.2300 $13.9000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.016667 $0.4000 $23.7500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.046804 $0.4200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.016667 $0.4600 $27.8900
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.016667 $77.5800 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 4 4 2.530137 $214.6500 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 1.030137 $52.6100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.016667 $0.2800 $16.7300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.046804 $1.0500 $22.4000
EXIT -EXIT EXIT ASSESSMENT 205 208 413.750000 $20687.5000 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 26.500000 $1987.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 42 43 82.785714 $4594.6100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 41 47 92.000000 $6900.0000 $75.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 288 360 647.186782 $36070.1200 $55.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.000000 $20000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 3.738889 $186.9500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 5.877778 $1351.8900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 297 324 447.110494 $22355.5500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 9.250000 $231.2500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 149 237.126189 $11856.3100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 3.200000 $80.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 45 61.038887 $3051.9400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.100000 $2.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 77 98.366668 $4918.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 97 105 140.539681 $7026.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.100000 $27.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 57 62 362.503172 $18125.1800 $50.0000
INTR -T1013 INTERPRETER 161 169 449.092855 $22454.6600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1145 1700 7821.948948 $78219.5000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 15.142857 $1081.8100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 8 9 71.095238 $5079.0400 $71.4400
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 14 78.333331 $5596.1500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.857143 $122.9400 $13.8800
TRAV -TRAVS Travel by mile 1340 2053 8296.499306 $3691.9400 $0.4400
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Subtotal (Total Children Is Unduplicated) 1422 4739 18115.921436 $205460.4000 $11.3400
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Total 5221 20662.779650 $307457.4900 $14.8800
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Number of Children (Unduplicated) With at Least One Authorization 1481