Summary Report for FSPSAs Initiated During the Report Period Center: 09
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 2255 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 19 19 27.473016 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 19 27.473016 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.316667 $6.2400 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.472223 $11.0900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 0.472223 $6.5500 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.472223 $4.2900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.472223 $13.1400 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.472223 $40.0700 $84.8500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.472223 $7.8900 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.155556 $3.4900 $22.4100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 17.428572 $871.4300 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 41.314286 $2065.7200 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.095890 $55.9500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
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Subtotal (Total Children Is Unduplicated) 13 27 67.144309 $3290.0500 $49.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.261111 $1305.5000 $4999.7900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.988889 $49.4500 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 258 308 274.817840 $13740.8800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 94 96 74.190208 $1854.7600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 58 60 52.500160 $2625.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.466667 $11.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 55 61.629192 $3081.4600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.033333 $0.8300 $24.9800
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 62 76.810798 $3840.5500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 74 75 73.275255 $3663.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.250000 $56.2500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 805 855 5814.123896 $290706.1000 $50.0000
INTR -T1013 INTERPRETER 3 3 14.857143 $742.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 99 106 666.019057 $47580.3900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.571429 $261.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 156 166 1105.469061 $78974.6800 $71.4400
SENS -V5264 EARMOLD 3 3 1.305556 $23.5000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 373 410 2974.109555 $212470.3400 $71.4400
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Subtotal (Total Children Is Unduplicated) 1190 2209 11198.679150 $661014.4500 $59.0300
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Total 2255 11293.296475 $664304.5000 $58.8200
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Number of Children (Unduplicated) With at Least One Authorization 1206