Summary Report for FSPSAs Ending During the Report Period Center: 52
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 1529 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 1.033333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.033333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.744444 $36.1000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.300000 $34.3900 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.300000 $28.8800 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.300000 $72.0700 $21.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.466667 $37.4400 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.202740 $9.4900 $46.7900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.202740 $24.2400 $119.5800
EXIT -EXIT EXIT ASSESSMENT 3 3 4.857143 $242.8600 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.344444 $17.5800 $51.0400
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 22 26.700456 $1363.0600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 4.744292 $242.2000 $51.0500
SCREEN-T1023 SCREENING 46 46 35.034728 $1751.7500 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 3.000000 $153.1500 $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 21 21 17.311110 $883.7300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 5 5 5.000000 $255.2500 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 103 124 111.508764 $5253.2300 $47.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 4.766667 $238.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 13 14 11.441630 $572.0900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 220 305 523.360961 $26168.0500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.533333 $13.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 133 171 339.705480 $16985.2700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 74 78 177.899996 $8894.9800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 171 186 373.419043 $18670.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 1.833333 $45.8300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 1.829158 $91.4600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 216 240 1215.688645 $60784.3900 $50.0000
INTR -T1013 INTERPRETER 2 2 30.057143 $1502.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 87 95 365.569446 $26116.2600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 19 25 107.709524 $6160.9700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 54 58 290.423805 $20747.9000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 52.566668 $3004.7100 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $237.1200 $237.1200
SENS -V5264 EARMOLD 3 3 2.355555 $42.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 188 205 1010.521431 $72191.5900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 7.290476 $101.1900 $13.8800
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Subtotal (Total Children Is Unduplicated) 434 1404 4518.972294 $267569.6400 $59.2100
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Total 1529 4631.514391 $272822.8700 $58.9100
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Number of Children (Unduplicated) With at Least One Authorization 456