Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 988 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 42 42 162.507143 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 162.507143 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.032877 $1.8600 $56.5300
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 3.000000 $71.1000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $18.1600 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
EXIT -EXIT EXIT ASSESSMENT 91 92 107.677984 $5383.9100 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 8 8 0.427396 $23.7200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 0.200000 $15.0000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.216667 $11.0600 $51.0600
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.032877 $1.6800 $51.0800
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 5.571429 $284.4200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 1.347641 $65.9600 $48.9400
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Subtotal (Total Children Is Unduplicated) 115 128 135.506871 $6513.4200 $48.0700
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 10.675256 $533.7600 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 110 127 76.600748 $3830.1100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 16 10.000000 $250.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 187 257 564.695231 $28234.7700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 33 78.305869 $3915.2800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 22 46.085715 $2304.3000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 86 181.828569 $9091.4100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 201 229 1589.671428 $79483.5900 $50.0000
INTR -T1013 INTERPRETER 4 4 20.642857 $1032.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 72.128572 $5152.8600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 17.000000 $1214.4800 $71.4400
SENS -V5264 EARMOLD 1 1 1.044444 $18.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 21 200.142857 $14298.2200 $71.4400
TRAV -TRAVS Travel by mile 3 3 28.142858 $12.5200 $0.4500
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Subtotal (Total Children Is Unduplicated) 401 818 2896.964404 $149372.2300 $51.5600
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Total 988 3194.978418 $155885.6500 $48.7900
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Number of Children (Unduplicated) With at Least One Authorization 500