Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 2775 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 1 1 1.766667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.766667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 27 4.081737 $197.9700 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.433333 $25.3600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.131507 $2.8900 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 2.433333 $21.2900 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.433333 $53.1400 $21.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 0.101370 $3.8900 $38.3800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.433333 $62.1200 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 9.714286 $454.6300 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 9.714286 $1161.8300 $119.6000
EXIT -EXIT EXIT ASSESSMENT 54 54 34.930138 $1746.5100 $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 129 130 111.804084 $8385.4000 $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 140 142 105.875317 $5876.1500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 42 43 28.145201 $2110.9100 $75.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 7 8 1.068190 $54.5300 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 19 6.756697 $344.9100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 10 13 1.423519 $72.6700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 22 22 13.274982 $677.6800 $51.0500
SCREEN-T1023 SCREENING 4 5 0.793379 $39.6700 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.035616 $1.8200 $51.0300
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.123288 $6.2900 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 18 3.049011 $155.6500 $51.0500
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Subtotal (Total Children Is Unduplicated) 282 534 362.909355 $23038.4600 $63.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 33 5.784705 $28924.5000 $5000.1700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.433333 $121.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 56 63 17.394079 $869.6800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 5.040277 $126.0100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 164 192 322.415002 $16120.7500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 9.557143 $238.9300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 58 90.892856 $4544.6400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.666666 $66.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 30 30 50.533334 $2526.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.200000 $55.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 133 138 228.280178 $11414.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 3 6.733334 $168.3400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 17 615.000001 $15374.9900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 206 222 1457.392366 $72869.5600 $50.0000
INTR -T1013 INTERPRETER 10 16 62.964905 $3148.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 267 444 1766.402780 $17664.0000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 66 69 464.194043 $33162.0000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 78 81 571.390479 $40820.1300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 1.285714 $73.4900 $57.1600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 9.714286 $4606.9100 $474.2400
SENS -V5264 EARMOLD 2 2 11.336508 $204.0600 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 78 81 617.571430 $44119.2600 $71.4400
TRAV -TRAVS Travel by mile 342 774 114319.638680 $50872.2500 $0.4500
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Subtotal (Total Children Is Unduplicated) 385 2240 120640.822099 $348091.7200 $2.8900
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Total 2775 121005.498121 $371130.1800 $3.0700
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Number of Children (Unduplicated) With at Least One Authorization 407