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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1011 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 24 24 16.733333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 16.733333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 4.833333 $113.5300 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.833333 $11.5600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.833333 $19.7500 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 10.833333 $98.3700 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 10.833333 $301.4900 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.833333 $32.0600 $38.4700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 11 11 10.833333 $180.9200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.833333 $18.6700 $22.4000
EXIT -EXIT EXIT ASSESSMENT 80 80 89.122983 $4456.1500 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.052055 $3.9100 $75.0600
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.052055 $2.8900 $55.5500
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 0.142466 $7.9100 $55.5100
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.071233 $5.3400 $74.9700
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 9.000000 $459.4500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 3.068493 $156.6500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 1.061111 $54.1700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.3000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 5.947032 $303.5900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 4 1.713166 $83.8400 $48.9400
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Subtotal (Total Children Is Unduplicated) 119 150 153.236147 $6429.6400 $41.9600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.071233 $53.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 147 169 118.133466 $5906.7600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 9 6.666667 $166.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 207 244 515.609514 $25780.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 7.066666 $176.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 52 94.533332 $4726.6600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 2 2.833334 $70.8400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 29 48.161902 $2408.0900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.833333 $70.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 96 108 215.638092 $10781.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.266666 $81.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 162 167 1112.907945 $55645.4000 $50.0000
INTR -T1013 INTERPRETER 2 2 21.433333 $1071.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 51.285714 $3663.8500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 29.142857 $2081.9700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.714286 $498.1100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 32 268.321428 $19168.9000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 16.000000 $222.0800 $13.8800
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Subtotal (Total Children Is Unduplicated) 417 837 2526.619768 $138036.0300 $54.6300
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Total 1011 2696.589248 $144465.6700 $53.5700
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Number of Children (Unduplicated) With at Least One Authorization 511