Summary Report for FSPSAs Initiated During the Report Period Center: 07
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 1597 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 4 4 14.400795 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 14.400795 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 3.200000 $150.6900 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 4.000000 $59.7200 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 4.000000 $76.8000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 4.000000 $41.6800 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 4.000000 $87.8000 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 12 12 5.298629 $46.3600 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 2.000000 $16.1200 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 4.898629 $106.9900 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 3.000000 $86.7000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $65.1400 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $38.3700 $38.3700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 10 10 3.898629 $89.2800 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 3.000000 $76.5900 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.533333 $71.7600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.933333 $111.6200 $119.6000
EXIT -EXIT EXIT ASSESSMENT 41 41 18.909743 $945.4800 $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 35 35 38.087664 $2856.6000 $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
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 1.000000 $51.0500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 1.950000 $99.5500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 5 1.317200 $67.2400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 27 27 47.566884 $2428.2800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 8 8 3.894445 $198.8100 $51.0500
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Subtotal (Total Children Is Unduplicated) 163 266 211.726844 $10842.6200 $51.2100
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.400000 $20.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 11 11 7.441934 $372.0900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.966667 $948.8300 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 124 135 203.508812 $10175.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 4 5.477777 $136.9400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 187 294 764.102041 $38205.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 10 16.600000 $415.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 56.995239 $2849.7600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 11.280953 $564.0500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 90.633335 $4531.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.000000 $100.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 621 681 5096.838102 $254841.8100 $50.0000
INTR -T1013 INTERPRETER 7 7 54.285714 $2714.2800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 14 94.857143 $6776.5900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 13 16 110.219047 $7874.0500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.571429 $489.9400 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $474.2400 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 3.000000 $1422.7200 $474.2400
SENS -V5264 EARMOLD 3 3 10.033333 $180.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 60 358.957146 $25643.8900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 20.285715 $281.5700 $13.8800
TRAV -TRAVS Travel by mile 42 50 297.361902 $132.3300 $0.4400
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Subtotal (Total Children Is Unduplicated) 677 1327 7220.816289 $359150.9500 $49.7400
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Total 1597 7446.943928 $369993.5800 $49.6800
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Number of Children (Unduplicated) With at Least One Authorization 715