Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6082 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 53 54 179.437301 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 11.859883 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 2.000000 $74.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 58 60 193.297184 $74.0000 $0.3800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 18 9.041324 $438.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.032877 $1.5500 $47.1200
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 7.479366 $111.6700 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 6 8.479366 $162.8000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 6 8.479366 $88.3600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 1.455556 $31.9500 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 7.479366 $65.4400 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 5 5 7.479366 $60.2800 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 7.857144 $171.6000 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 7.479366 $216.1500 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.555556 $36.1900 $65.1500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 7.668255 $195.7700 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.789955 $83.7700 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.263013 $31.4500 $119.5900
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 142 146 290.066667 $14503.3400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 25 40.513698 $3038.5300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 7.000000 $525.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 13.500000 $1012.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 20 20 33.005479 $2475.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 19 19 27.010959 $1499.1000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 253 257 548.201366 $41115.1100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 84 84 167.078082 $12530.8600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 80 80 130.013700 $9751.0200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 329 330 676.489137 $37545.1400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 124 145 211.137282 $15835.2800 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 2.701370 $137.9100 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 10.075571 $514.3600 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 5.422222 $84.5900 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 23 23 39.226604 $2002.5200 $51.0500
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Subtotal (Total Children Is Unduplicated) 677 1239 2280.982013 $144543.2600 $63.3700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 18 19.761079 $98804.5000 $4999.9500
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.900000 $45.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 21 22 33.094008 $1654.6900 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 4.142857 $296.6700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.178083 $281.8000 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 209 231 222.265358 $11113.2600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 3.886111 $97.1500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 125 189 323.509404 $16175.4600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 4.000001 $100.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 24 97.173017 $4858.6500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 33 92.266288 $4613.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 57 59 90.507937 $4525.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 13.761905 $344.0500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 700 751 4479.627224 $223981.3100 $50.0000
INTR -T1013 INTERPRETER 81 87 320.084245 $16004.2200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 941 1413 6433.711907 $64337.1000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 37 238.590477 $17044.9100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 16.419048 $939.1700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 73 83 486.514289 $34756.5800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.266667 $15.2400 $57.1700
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 2.665982 $173.2900 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 4 4 2.640791 $313.0900 $118.5600
SENS -V5060 BEHIND EAR HEARING AID
3 3 2.131507 $505.4200 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 1.123288 $532.7100 $474.2500
SENS -V5264 EARMOLD 12 13 10.950077 $197.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 149 166 963.547619 $68835.8600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 4.712699 $65.4100 $13.8800
TRAV -TRAVS Travel by mile 1085 1621 21536.590066 $9583.7800 $0.4500
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Subtotal (Total Children Is Unduplicated) 1132 4783 35406.021934 $580195.1600 $16.3900
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Total 6082 37880.301131 $724812.4200 $19.1300
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Number of Children (Unduplicated) With at Least One Authorization 1407