Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 3066 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 5 5 3.366666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 1.377778 $50.9800 $37.0000
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Subtotal (Total Children Is Unduplicated) 8 8 4.744444 $50.9800 $10.7400
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.350000 $6.2700 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.350000 $7.4700 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.350000 $4.4100 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.350000 $7.5400 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.350000 $2.8900 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.350000 $3.1700 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.350000 $8.8600 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.350000 $12.2400 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 3.900000 $300.8100 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.350000 $6.4900 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.350000 $7.2400 $20.6800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 12 12 19.857143 $1102.0700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 11 18.857143 $1414.2800 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 29 30 11.738890 $599.2800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 99 103 36.683334 $1872.6900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 49 50 22.507138 $1148.9700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.333333 $17.0200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 75 77 62.322225 $3181.5600 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.300000 $15.3200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 177 184 111.892855 $5712.1100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 39 39 12.666670 $646.6500 $51.0500
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Subtotal (Total Children Is Unduplicated) 364 525 305.558731 $16152.3400 $52.8600
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.233333 $53.6600 $229.9700
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 109 62.339678 $3116.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.522222 $13.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 19 23.114287 $1155.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 345 352 177.606343 $8880.2800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 65 65 447.714294 $11192.8500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 553 569 3732.431028 $186621.3200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 586 990 4430.077848 $44300.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 107 108 578.761907 $41346.7000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 4 4 13.714286 $784.4600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 107 109 617.126992 $44087.4700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 34.357142 $1963.8600 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 145 151 854.663498 $61057.1000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 17.428571 $996.9200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 43.571429 $604.7700 $13.8800
TRAV -TRAVS Travel by mile 20 45 23516.547623 $10464.8600 $0.4500
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Subtotal (Total Children Is Unduplicated) 754 2533 34550.210481 $416640.7000 $12.0600
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Total 3066 34860.513656 $432844.0200 $12.4200
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Number of Children (Unduplicated) With at Least One Authorization 779