Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 5999 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 30 30 95.529368 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 5.717026 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 2.544445 $94.1500 $37.0000
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Subtotal (Total Children Is Unduplicated) 34 37 103.790839 $94.1500 $0.9100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 23 57.126638 $2770.6500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 9 10 4.222223 $63.0400 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 9 10 4.222223 $81.0700 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 10 4.222223 $44.0000 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 9 10 4.007937 $87.9800 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 10 4.222223 $36.9500 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 9 10 4.222223 $34.0300 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 9 10 4.222223 $92.2200 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 9 10 4.222223 $122.0200 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 8 9 3.007937 $195.9400 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 10 4.222223 $107.8000 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.128767 $52.8300 $46.8000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $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 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 14.077778 $1055.8400 $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 251 255 400.123284 $30009.2600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 82 82 139.000000 $10425.0000 $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 326 327 514.489137 $28554.1400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 124 145 211.137282 $15835.2800 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 3.285714 $164.2900 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 3 3 3.000000 $153.1500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 1.000000 $51.0500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 14 14 169.964581 $8676.7000 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 85.056697 $4342.1400 $51.0500
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Subtotal (Total Children Is Unduplicated) 656 1270 2171.794039 $134999.8400 $62.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 23 60.787716 $303938.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 2.566667 $128.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 91.100359 $4555.0200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.128767 $270.0100 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 210 228 245.779362 $12288.9500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 2.319445 $57.9900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 109 135 305.554972 $15277.7600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 23 143.821428 $7191.0700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.566667 $14.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 52 159.985119 $7999.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 80 161.599206 $8079.9700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.066667 $76.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 689 727 4830.255557 $241512.7200 $50.0000
INTR -T1013 INTERPRETER 70 80 274.831865 $13741.5900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 937 1405 7150.771422 $71507.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 26 192.019178 $13717.8400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 91 97 605.415881 $43250.8800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 41.669842 $2381.8500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.094444 $6.1400 $64.9700
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.128767 $61.0800 $474.3600
SENS -V5264 EARMOLD 4 4 4.500001 $81.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 145 171 1015.661443 $72558.8600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.714286 $155.2600 $57.2000
TRAV -TRAVS Travel by mile 982 1614 23567.193592 $10487.4000 $0.4400
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Subtotal (Total Children Is Unduplicated) 1021 4692 38863.532653 $829339.9800 $21.3400
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Total 5999 41139.117531 $964433.9600 $23.4400
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Number of Children (Unduplicated) With at Least One Authorization 1116