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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 962 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 27 27 223.461905 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 27 27 223.461905 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.866667 $15.5300 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.866667 $39.8500 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.866667 $10.9300 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.866667 $40.2300 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.915982 $15.8300 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.915982 $48.4900 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.866667 $65.2800 $34.9700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.915982 $16.9900 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.866667 $38.6000 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.169863 $7.6500 $45.0100
EXIT -EXIT EXIT ASSESSMENT 80 80 66.198553 $3309.9400 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 0.350685 $19.4700 $55.5200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 0.210959 $15.8300 $75.0100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 0.154338 $7.8800 $51.0700
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $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 4 4 1.561112 $79.7000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 2.333333 $119.1200 $51.0500
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Subtotal (Total Children Is Unduplicated) 102 121 88.926791 $4055.5100 $45.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.866667 $43.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 0.638128 $31.9000 $49.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 126 138 117.960115 $5898.0200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 207 348 895.427939 $44771.3900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 5.033334 $125.8400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 15 51.709524 $2585.4800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 3.500000 $175.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.866667 $21.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 28 99.052379 $4952.6200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.500001 $87.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 180 197 1502.190485 $75109.5000 $50.0000
INTR -T1013 INTERPRETER 6 10 76.857143 $3842.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 46.428573 $3316.8600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.714286 $326.8600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 4 20.714287 $1479.8200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 21 186.428573 $13318.4500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 9.857143 $136.8200 $13.8800
TRAV -TRAVS Travel by mile 21 25 212.133334 $94.4000 $0.4500
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Subtotal (Total Children Is Unduplicated) 418 814 3239.884134 $161318.4500 $49.7900
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Total 962 3552.272830 $165373.9500 $46.5500
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Number of Children (Unduplicated) With at Least One Authorization 485