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: 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 2194 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 58.566667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 58.566667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 17.076712 $964.6600 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.7100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 8 8.350000 $196.1400 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 6.000000 $83.2200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 8 8.350000 $197.9000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 8.115079 $73.6900 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $9.9600 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 12 12 18.503175 $514.9400 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 7 7.288889 $618.3900 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 5 5 4.458752 $227.7100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 24 26 23.788889 $397.2700 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 6.288889 $140.8700 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.350000 $105.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $230.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 84 85 85.002284 $4250.1200 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 0.095890 $7.2000 $75.0900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 8.095890 $449.3300 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 21 21 14.534247 $806.6600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 21 21 14.534247 $1090.0900 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 14 14 14.433333 $736.8200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 31 31 45.744445 $2335.2600 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 9 9 8.127778 $414.9200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 13 25.455555 $1299.5000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 6.988889 $356.7800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 45 47 47.026549 $2400.7000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 10 10 11.000000 $561.5500 $51.0500
SPCH -92524GT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.027778 $1.4200 $51.0900
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 8 8 7.722223 $344.0300 $44.5500
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Subtotal (Total Children Is Unduplicated) 267 386 411.359493 $19230.4100 $46.7500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.560959 $2805.0000 $5000.3700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.872222 $193.6100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 3.000000 $214.8300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.455556 $564.7900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 150 175 133.084699 $6654.3200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 21 23 19.577778 $489.4500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 243 274 615.919072 $30795.9600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 6.527977 $163.2000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 99 106 175.516668 $8775.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.366667 $34.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 39 88.742855 $4437.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 129 154 257.334920 $12866.7400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.833333 $70.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 661 708 5362.473809 $268123.7300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 19 91.428570 $4571.4200 $50.0000
INTR -T1013 INTERPRETER 3 4 12.652381 $632.6200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 62 67 476.998412 $34076.7700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 4 14.571428 $1040.9900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.142857 $637.3700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 21.714286 $1242.0600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 33 36 282.223810 $20162.0600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 3 10.142856 $724.6100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.285714 $244.9700 $57.1600
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 116 124 1004.313490 $71748.2100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 8 35.428571 $2531.0200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 14 16 124.492856 $1727.9600 $13.8800
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Subtotal (Total Children Is Unduplicated) 809 1787 8764.661746 $475572.6200 $54.2600
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Total 2194 9234.587906 $494803.0400 $53.5800
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Number of Children (Unduplicated) With at Least One Authorization 883