Summary Report for FSPSAs Ending During the Report Period Center: 07
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 2078 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 31 32 28.203174 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 31 32 28.203174 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 16.291193 $920.2900 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 8 8 9.617504 $189.5600 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 17 17 22.330289 $524.5400 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 15 15 21.050837 $291.9700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 16 23.911111 $566.6900 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 20 20 17.228919 $156.4400 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 35 35 34.901750 $971.3100 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 6 6 5.911111 $227.4000 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 10 10 16.219178 $1376.0400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 3.000000 $153.2100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 30 30 26.264536 $438.6200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 8.911111 $199.6100 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 2.611111 $117.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 8.524603 $980.3300 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 1.005479 $50.2800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 73 74 82.673389 $4133.6700 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.126027 $9.4600 $75.0400
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.126027 $7.0000 $55.5300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 49 49 1.460265 $81.0800 $55.5200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 49 49 1.460265 $109.5700 $75.0300
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 6.000000 $306.3000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 21 16.326637 $833.4700 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 1.327777 $67.7800 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 5.572222 $284.4600 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 1.533332 $78.2700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 45 46 31.791477 $1622.9600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 6 6 7.000000 $357.3500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $146.8200 $48.9400
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Subtotal (Total Children Is Unduplicated) 270 462 382.176150 $15508.2600 $40.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.477778 $23.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 5.793347 $289.6700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 147 162 119.753783 $5987.7700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 216 248 496.004768 $24800.2700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 45 47 87.985712 $4399.2800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 30 53.266666 $2663.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 107 119 224.428571 $11221.4200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 9.542857 $238.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 695 730 4910.485675 $245524.3500 $50.0000
INTR -T1013 INTERPRETER 4 4 22.466667 $1123.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 48 328.285715 $23452.7100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 2 8.428571 $482.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 22 23 135.866666 $9706.3200 $71.4400
SENS -V5264 EARMOLD 1 1 0.911111 $16.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 132 142 1007.999990 $72011.5600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 47.857143 $664.2600 $13.8800
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Subtotal (Total Children Is Unduplicated) 801 1584 7467.055020 $418174.3400 $56.0000
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Total 2078 7877.434344 $433682.6000 $55.0500
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Number of Children (Unduplicated) With at Least One Authorization 905