Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 3427 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 1 1 0.566667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.566667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 39 43 16.238128 $787.5500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.252511 $22.4400 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.221918 $4.7400 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 0.779985 $9.8400 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.219178 $4.7200 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.441096 $3.6400 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.441096 $11.1600 $25.3100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.219178 $4.0700 $18.5500
EXIT -EXIT EXIT ASSESSMENT 63 64 94.586107 $4729.3000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 6.010958 $450.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 5 8.005479 $600.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 10.013698 $555.7600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 114 114 171.175331 $12838.1900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 56 56 87.065748 $6529.9500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 113 114 166.664370 $9249.9100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 52 53 98.955966 $7421.7100 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 1.400304 $71.4900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 1.791781 $91.4700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 24 25 7.931812 $404.9100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.454566 $23.2100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 2.302511 $117.5400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 2.471233 $126.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 30 30 6.490031 $331.3100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 29 30 7.119101 $363.4200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 10 10 4.663796 $238.0900 $51.0500
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Subtotal (Total Children Is Unduplicated) 308 596 702.921361 $45394.3200 $64.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 37 42 15.984552 $79923.5000 $5000.0500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.221918 $51.0400 $229.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 67 33.371758 $1668.5500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.255556 $31.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 259 306 509.029731 $25451.5200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 5.100000 $127.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 87 92 137.683333 $6884.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 5.550000 $138.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 37 54.033334 $2701.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 183 187 273.022230 $13651.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.383333 $34.5800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 11 29.285711 $2147.2400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 496.428568 $12410.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 284 298 1734.631746 $86731.5700 $50.0000
INTR -T1013 INTERPRETER 29 46 114.879060 $5743.9500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 333 552 2163.660333 $21636.5900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 60 62 466.519047 $33328.1300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 70 73 479.480854 $34254.1300 $71.4400
SENS -V5264 EARMOLD 1 1 0.221918 $3.9900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 74 555.033401 $39651.5900 $71.4400
TRAV -TRAVS Travel by mile 392 954 159933.840777 $71170.5600 $0.4500
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Subtotal (Total Children Is Unduplicated) 425 2830 167010.617160 $437742.2700 $2.6200
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Total 3427 167714.105188 $483136.5900 $2.8800
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Number of Children (Unduplicated) With at Least One Authorization 447