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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1852 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 31 31 37.972221 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 31 31 37.972221 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.131507 $7.4300 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.533333 $10.5100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.722374 $40.4600 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 7.722374 $107.1100 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 14 14 23.533333 $557.7400 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 18.247619 $165.6900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 16 16 19.751729 $549.6900 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.533333 $20.5200 $38.4700
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 16 16 21.506371 $359.1600 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 1.179908 $26.4300 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 5.716666 $257.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.738888 $659.9600 $115.0000
EXIT -EXIT EXIT ASSESSMENT 88 89 81.747377 $4087.3800 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.038356 $2.8800 $75.0900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.038356 $2.1300 $55.5600
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 42 42 5.652051 $313.7000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 41 44 1.813696 $136.0500 $75.0100
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 2.177778 $111.1800 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.116667 $5.9600 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 10.000000 $510.5000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 10.482192 $535.1200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.150685 $7.6900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 9.000000 $459.4500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 3.388888 $173.0000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 1.450000 $74.0200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 39 40 43.419809 $2216.5800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 5 5 4.155556 $212.1400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 0.850000 $41.6000 $48.9400
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Subtotal (Total Children Is Unduplicated) 260 360 288.798846 $12155.5400 $42.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.719634 $35.9800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 21 23 9.269407 $463.4700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 0.282192 $20.2100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 14.888889 $3424.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 126 145 83.771745 $4188.6500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 17 10.433333 $260.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 155 201 428.311906 $21415.5900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.900000 $47.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 33 91.747619 $4587.3700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 5.671429 $141.7900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 26 48.025397 $2401.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 67 75 165.157145 $8257.8500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.066666 $26.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 641 686 5557.855590 $277892.8100 $50.0000
INTR -T1013 INTERPRETER 3 4 14.785714 $739.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 46 323.714291 $23126.1600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.000000 $228.8000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 30 31 295.285713 $21095.2200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 26.092064 $1491.4200 $57.1600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 2 2 1.733333 $31.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 130 139 1216.485723 $86905.7200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 62.438095 $866.6400 $13.8800
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Subtotal (Total Children Is Unduplicated) 764 1461 8368.635885 $468674.8700 $56.0000
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Total 1852 8695.406952 $480830.4100 $55.3000
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Number of Children (Unduplicated) With at Least One Authorization 860