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: 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 8388 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 1 1 0.800000 $29.6000 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 68 68 249.028888 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 795 799 21868.751579 $809143.8600 $37.0000
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Subtotal (Total Children Is Unduplicated) 817 868 22118.580467 $809173.4600 $36.5800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 26 21.131506 $1024.8800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 3 1.477778 $29.1300 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 3 1.477778 $34.7100 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 3 1.477778 $20.5000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 3 1.477778 $35.0200 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 5 2.675038 $24.2900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 3 1.477778 $41.1300 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 4 3.477778 $133.7900 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 13 12.119482 $1028.2200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 5 5 3.919482 $200.1700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 3 1.477778 $24.6800 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 4 1.675038 $37.5200 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 2.658371 $119.6300 $45.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
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 216 216 396.005479 $29700.4100 $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 33 33 57.500000 $4312.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 477 485 895.934050 $49724.3400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 352 417 782.428571 $58682.1500 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.147945 $109.6500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 14 14 20.285714 $1035.5900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.147945 $58.6000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 9.000000 $459.4500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 2.766667 $41.5000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 8.000000 $408.4000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 14 13.257534 $676.8000 $51.0500
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Subtotal (Total Children Is Unduplicated) 887 1597 2859.747268 $182955.9900 $63.9800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 19 40.928158 $204641.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.394445 $19.7300 $50.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 12 9.908372 $495.4300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 14 15 18.527397 $4261.3000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 304 329 359.764490 $17988.2500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 11 11 31.035714 $775.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 126 141 266.572218 $13328.6000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.533333 $63.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 54 56 87.972219 $4398.6000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 67 109.940472 $5497.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 121 199.139680 $9956.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.566666 $64.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 903 948 6367.036522 $318351.7600 $50.0000
INTR -T1013 INTERPRETER 159 174 416.640476 $20832.0200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1200 1684 8737.918942 $87379.1500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 47 50 332.323810 $23741.2100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 34.285714 $1961.1400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 78 83 537.742856 $38416.3500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 12 12 55.461905 $3170.2000 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 2 2 2.982192 $53.6800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 129 134 977.315871 $69819.4200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 74.000000 $1027.1200 $13.8800
TRAV -TRAVS Travel by mile 1248 2044 9202.040731 $4094.9100 $0.4400
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Subtotal (Total Children Is Unduplicated) 1305 5923 27870.032183 $831249.2100 $29.8300
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Total 8388 52848.359918 $1823378.6600 $34.5000
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Number of Children (Unduplicated) With at Least One Authorization 1415