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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 8320 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 2 2 0.688889 $25.4900 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 64 66 211.462375 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 707 712 17986.501598 $665500.6000 $37.0000
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Subtotal (Total Children Is Unduplicated) 732 780 18198.652862 $665526.0900 $36.5700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 33 33 28.331431 $1374.0800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.566667 $144.9900 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.7100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.4900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.788889 $42.4000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $18.1600 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.366667 $3.6500 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 3 5.000000 $192.3500 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 10 10 9.977778 $846.5200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 1.366667 $69.8000 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $16.7000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.577778 $206.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.577778 $181.4500 $115.0000
EXIT -EXIT EXIT ASSESSMENT 221 223 445.000000 $22250.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 20 20 36.500000 $2737.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 30 44 79.505479 $5962.9100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 30 56.000000 $3108.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 145 145 262.000000 $19650.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 26 26 45.500000 $3412.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 24.000000 $1800.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 343 345 627.500000 $34826.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 284 338 602.571428 $45192.8600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.106849 $107.5500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 13.000000 $663.6500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.106849 $107.5500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 8 10.000000 $510.5000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 4 9.303175 $139.5500 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 6.000000 $306.3000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 4.000000 $204.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 21 32.857143 $1677.3600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 5.000000 $222.7500 $44.5500
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Subtotal (Total Children Is Unduplicated) 772 1318 2335.504578 $146614.1200 $62.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 29 50.832574 $254163.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 10 15.514286 $775.7200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.783333 $56.0900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 13 13 12.601088 $2898.2500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 397 435 520.913648 $26045.6900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 47 49 57.644141 $1441.1100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 131 143 237.811902 $11890.5800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 6.866667 $171.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 53 78.938887 $3946.9400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 78 108.223019 $5411.1600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 42.000000 $1050.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 101 109 160.596028 $8029.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 13.066667 $326.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 891 965 5684.738088 $284236.9100 $50.0000
INTR -T1013 INTERPRETER 164 188 554.416669 $27720.8400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1129 1773 8008.746585 $80087.4500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 57 326.109524 $23297.2600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 7.266667 $415.6600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 105 114 582.424604 $41608.3800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 9 19.557144 $1117.9000 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.758600 $114.3100 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.969711 $110.5500 $114.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 3.969711 $1810.1800 $456.0000
SENS -V5264 EARMOLD 7 7 8.581889 $154.4800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 131 138 853.295242 $60959.3900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.428571 $530.7000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 12 13 90.295240 $1253.3000 $13.8800
TRAV -TRAVS Travel by mile 1269 2016 8339.177897 $3710.9300 $0.4400
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Subtotal (Total Children Is Unduplicated) 1361 6222 25794.528382 $843335.3600 $32.6900
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Total 8320 46328.685822 $1655475.5600 $35.7300
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Number of Children (Unduplicated) With at Least One Authorization 1625