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 5237 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 62 62 245.488097 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 73 73 1681.666663 $62221.6800 $37.0000
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Subtotal (Total Children Is Unduplicated) 133 136 1927.954760 $62251.2800 $32.2900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 24 19.131506 $927.8800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 2 0.477778 $9.4200 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 2 0.477778 $11.2200 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 2 0.477778 $6.6300 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 2 0.477778 $11.3200 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 3 0.675038 $6.1300 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 2 0.477778 $13.3000 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 3 2.477778 $95.3200 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.197260 $101.5800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.197260 $10.0800 $51.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 2 0.477778 $7.9800 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 3 0.675038 $15.1200 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.658371 $29.6300 $45.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
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 43 44 84.785714 $4705.6100 $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 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 291 373 659.914633 $36530.4100 $55.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 7.000000 $35000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 9 5.975038 $298.7600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 300 325 352.764490 $17638.2500 $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 53 54 85.805553 $4290.2700 $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 72 75 476.188890 $23809.4600 $50.0000
INTR -T1013 INTERPRETER 147 158 386.426190 $19321.3100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1200 1683 8733.633228 $87336.3000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 29.142857 $2081.9600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 10 57.190476 $4085.6800 $71.4400
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 18 128.038095 $9147.0400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 4.285714 $59.4900 $13.8800
TRAV -TRAVS Travel by mile 1247 2042 9189.755017 $4089.4400 $0.4400
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Subtotal (Total Children Is Unduplicated) 1291 4728 20070.993631 $237303.9000 $11.8200
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Total 5237 22658.863024 $336085.5900 $14.8300
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Number of Children (Unduplicated) With at Least One Authorization 1321