Summary Report for FSPSAs Ending During the Report Period Center: 07
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 1605 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 3 3 1.938890 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.938890 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 4.000000 $59.7200 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $76.8000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 4.000000 $41.6800 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 10 4.575342 $100.4300 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 2.956163 $25.8700 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 2.000000 $16.1200 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 10 2.956163 $64.5600 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $57.8000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 2.000000 $130.2800 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $76.7400 $38.3700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 7 7 0.769862 $17.6300 $22.9000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.205479 $56.4200 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $119.6000 $119.6000
EXIT -EXIT EXIT ASSESSMENT 35 35 17.964537 $898.2100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.068493 $5.1400 $75.0100
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 2.071233 $114.9500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 38 38 44.087664 $3306.6000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 6 6 2.238356 $167.8700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 48 48 39.115067 $2170.8900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 2.739727 $205.4800 $75.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 5 5 2.458524 $125.5100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.144444 $7.3700 $51.0300
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $51.0500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 31 31 53.805499 $2746.7600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 5 5 2.933333 $149.7400 $51.0500
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Subtotal (Total Children Is Unduplicated) 165 261 207.095365 $11096.7800 $53.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.098630 $5493.0000 $4999.8600
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.066667 $3.3400 $50.0200
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 10 6.891879 $344.5900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $239.2000 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 123 136 63.370293 $3168.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 3 3.144445 $78.6100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 190 331 852.359180 $42617.9800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 14 21 72.619051 $1815.4900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 8 12.400001 $620.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.633333 $131.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 12 15.419047 $770.9500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 7.685714 $192.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 603 680 4324.311626 $216215.5300 $50.0000
INTR -T1013 INTERPRETER 3 3 18.714286 $935.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 12.571428 $125.7200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 8 76.714286 $5480.4800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 14 15 93.071429 $6649.0100 $71.4400
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 1.000000 $474.2400 $474.2400
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 61 67 488.785716 $34918.8500 $71.4400
TRAV -TRAVS Travel by mile 26 34 211.633335 $94.1800 $0.4500
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Subtotal (Total Children Is Unduplicated) 645 1341 6267.490346 $320405.2300 $51.1200
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Total 1605 6476.524601 $331502.0100 $51.1900
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Number of Children (Unduplicated) With at Least One Authorization 737