Summary Report for FSPSAs Initiated During the Report Period Center: 07
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 1864 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 24 24 39.921429 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 39.921429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 2.000000 $97.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 21 21 35.000000 $1977.1500 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 7 9.360926 $219.8900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.633333 $50.3900 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 8 10.633333 $252.0100 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 12 12 11.707306 $106.3000 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 12 12 9.137975 $254.3100 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.633333 $24.3600 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 4.000000 $339.3600 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 1.172603 $59.8800 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 18 18 17.805936 $297.3600 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.555555 $34.8400 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.411110 $63.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.188889 $136.7200 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.005479 $0.2800 $50.1900
EXIT -EXIT EXIT ASSESSMENT 66 66 78.186761 $3909.3300 $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 51 51 1.465745 $81.3800 $55.5200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 51 51 1.465745 $109.9700 $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 11.000000 $561.5500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 7.000000 $357.3500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 21 22 19.794901 $1010.5300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.894445 $45.6600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 29.714286 $1516.9200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 9.677778 $494.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 4.483333 $228.8700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.244444 $165.6300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 53 54 42.759046 $2182.8500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 3 3.000000 $153.1500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.311112 $64.1700 $48.9400
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Subtotal (Total Children Is Unduplicated) 274 383 324.495428 $14862.2800 $45.8000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.488888 $74.4400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 4.896347 $244.8200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 3.000000 $214.8300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 139 152 137.013307 $6850.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 3 5.633334 $140.8400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 186 221 501.980954 $25099.0200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.066667 $51.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 47 50 103.614287 $5180.7100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 26 53.742859 $2687.1600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 86 99 225.719043 $11285.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 8.966667 $224.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 663 690 5918.830955 $295941.6100 $50.0000
INTR -T1013 INTERPRETER 2 2 4.000000 $200.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 36 286.588888 $20473.9200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 19.428571 $1111.3200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 23 25 202.790476 $14487.3700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.142857 $465.4500 $57.1600
SENS -V5264 EARMOLD 1 1 0.955556 $17.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 111 118 837.657140 $59842.2100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 82.714285 $1148.0700 $13.8800
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Subtotal (Total Children Is Unduplicated) 772 1457 8412.231081 $455971.4500 $54.2000
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Total 1864 8776.647938 $470833.7300 $53.6500
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Number of Children (Unduplicated) With at Least One Authorization 858