Summary Report for FSPSAs Ending During the Report Period Center: 02
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 2926 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 38 40 15.712395 $762.0500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 0.115068 $1.7200 $14.9300
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 0.191780 $2.0000 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 0.545205 $11.9700 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.115068 $1.0100 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.115068 $2.5100 $21.8500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.115068 $2.6400 $22.9100
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 3.505283 $164.0500 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.505283 $419.2300 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 6 6 3.761643 $188.0800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 54 55 33.688890 $1684.4600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 2.036984 $152.7800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 0.016437 $1.2400 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 4.020547 $223.1400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 130 131 111.634221 $8372.6600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 16.079447 $1205.9800 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 142 144 115.705454 $6421.7200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 43 44 38.145201 $2860.9100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 6 7 1.670700 $85.2800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 25 7.032805 $359.0100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 8 11 13.185357 $673.1000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 34 36 7.181430 $366.6000 $51.0500
SCREEN-T1023 SCREENING 12 14 4.229225 $211.4700 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.038356 $1.9600 $51.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 20 5.288433 $269.9700 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 319 594 387.635348 $24445.5400 $63.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 39 40 15.351817 $76759.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.156164 $7.8100 $50.0100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.076712 $18.3500 $239.1600
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 61 69 21.963641 $1098.1700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 7 9.847507 $246.1900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 170 212 361.397937 $18069.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 10 25.238094 $630.9500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 49 73.526171 $3676.3000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.500000 $12.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 28 51.408331 $2570.4100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.166667 $29.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 125 132 226.447226 $11322.3800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 3.861111 $96.5300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 18 565.633334 $14140.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 207 222 1249.251598 $62462.5500 $50.0000
INTR -T1013 INTERPRETER 11 17 30.214807 $1510.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 302 479 1787.519314 $17875.1600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 69 72 511.542852 $36544.6200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 84 87 610.964580 $43647.3100 $71.4400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 3.505283 $1662.3500 $474.2400
SENS -V5264 EARMOLD 2 2 3.543639 $63.7900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 87 90 627.061385 $44797.2700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.213699 $2.9700 $13.8800
TRAV -TRAVS Travel by mile 432 786 107170.289891 $47690.7800 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 479 2332 113350.681760 $384935.9900 $3.4000
-------------------------------------------------------------------------------------------------------------------------------------
Total 2926 113738.317108 $409381.5300 $3.6000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 499