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 4110 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
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Subtotal (Total Children Is Unduplicated) 31 34 101.246394 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 20 55.804415 $2706.5100 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.624603 $24.2600 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.624603 $31.1900 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.624603 $16.9300 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.624603 $35.6600 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.624603 $14.2200 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 1.624603 $13.0900 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.624603 $35.4800 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.624603 $46.9500 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.624603 $105.8300 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.624603 $41.4800 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.128767 $6.0300 $46.8100
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 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.002740 $111.1500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 35 35 59.500000 $4462.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 19.000000 $1425.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 15 15 27.500000 $2062.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 62 62 101.802152 $5650.0200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 15 23.505479 $1762.9100 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 3.285714 $164.2900 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 3 3 8.976985 $458.2800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.104110 $5.3100 $51.0500
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Subtotal (Total Children Is Unduplicated) 250 339 617.928538 $34383.3200 $55.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 3.730593 $18653.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.566667 $78.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 89.653175 $4482.6600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.128767 $30.8100 $239.2600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 203 221 237.768404 $11888.4000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 2.316667 $57.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 106 131 301.054972 $15052.7600 $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 49 50 157.118452 $7855.9300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 72 79 160.599206 $8029.9700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.066667 $76.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 88 94 610.604765 $30530.2300 $50.0000
INTR -T1013 INTERPRETER 69 79 272.831865 $13641.5900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 929 1393 7089.819040 $70898.1600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 43.142858 $3082.1200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 10 86.428572 $6174.4500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 19.000000 $1086.0400 $57.1600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.128767 $61.0800 $474.3600
SENS -V5264 EARMOLD 1 1 1.566667 $28.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 31 186.238096 $13304.8600 $71.4400
TRAV -TRAVS Travel by mile 975 1600 23364.812639 $10397.3400 $0.4400
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Subtotal (Total Children Is Unduplicated) 999 3737 32775.964934 $222615.7400 $6.7900
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Total 4110 33495.139866 $256999.0700 $7.6700
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Number of Children (Unduplicated) With at Least One Authorization 1041