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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1051 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 21 21 25.433332 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 21 21 25.433332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 4.000000 $93.9600 $23.4900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 9.000000 $81.7200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 8.000000 $222.6400 $27.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 9 9.000000 $150.3000 $16.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.666667 $30.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 81 82 90.019481 $4500.9700 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.079452 $4.4100 $55.5300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 6.065754 $336.6500 $55.5000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 7.285714 $371.9400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 15.714286 $802.2200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.122222 $6.2400 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 5.603424 $286.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.630441 $72.6300 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 118 138 160.187441 $7112.8800 $44.4000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.666667 $33.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 3.046575 $152.3300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 140 165 131.681525 $6584.1500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 16 18 10.922223 $273.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 233 270 533.845229 $26692.2500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 4.004167 $100.1100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 59 93.611905 $4680.6000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.166667 $54.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 35 71.204761 $3560.2500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 124 192.380959 $9619.0900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 8.685714 $217.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 164 174 1291.600001 $64580.0100 $50.0000
INTR -T1013 INTERPRETER 2 3 11.285714 $564.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 39.142857 $2796.3600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 14.000000 $1000.1600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 18 113.285713 $8093.1200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 4.714286 $65.4300 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 423 892 2529.244963 $134525.8300 $53.1900
-------------------------------------------------------------------------------------------------------------------------------------
Total 1051 2714.865736 $141638.7100 $52.1700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 499