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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 3602 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 5.211111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 5.211111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 49 55 8.937518 $433.4500 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 0.506620 $6.3900 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 6 0.886604 $19.1100 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.183333 $1.5100 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.183333 $4.6400 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.046575 $3.5900 $77.1700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 2 0.216438 $4.0200 $18.5600
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.933333 $87.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 0.706849 $81.2900 $115.0100
EXIT -EXIT EXIT ASSESSMENT 71 71 51.342468 $2567.1100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 2.021916 $151.6500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.005479 $0.4100 $75.2900
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 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 131 131 75.468472 $5660.2200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 57 57 53.654783 $4024.1500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 157 157 107.519157 $5967.3700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 67 67 15.802726 $1185.2600 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.002740 $0.1400 $49.2700
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.158904 $8.1100 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.043836 $2.2400 $51.0100
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 0.756164 $38.6000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 12 14 2.996348 $152.9600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 5 0.924657 $47.2100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 7.924854 $404.5600 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 5 0.984551 $50.2600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 0.533790 $27.2500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 8 4.265524 $217.7600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 13 14 3.935161 $200.9000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 9 2.307686 $117.8100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 0.619178 $31.6100 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.164384 $8.3900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 0.501370 $25.6000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 29 29 6.054791 $309.0900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 1.320548 $67.4200 $51.0500
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Subtotal (Total Children Is Unduplicated) 361 681 354.926527 $22019.3000 $62.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 52 59 10.634851 $53172.5000 $4999.8300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 86 106 19.364381 $968.1600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 233 275 391.569187 $19578.4600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.550000 $13.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 85 97 141.250000 $7062.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 57 80.300001 $4015.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 178 185 250.933331 $12546.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.666667 $16.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 11 320.714286 $8017.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 278 288 1607.203691 $80360.2800 $50.0000
INTR -T1013 INTERPRETER 18 25 57.790460 $2889.5100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 330 528 1783.993605 $17839.9200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 77 81 527.882451 $37711.9300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.142857 $294.1700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 95 101 641.166659 $45804.9700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 2.128571 $121.6700 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 3 0.706849 $161.1700 $228.0200
SENS -V5264 EARMOLD 2 3 0.706849 $12.7200 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 102 608.014277 $43436.5700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.285715 $142.7700 $13.8800
TRAV -TRAVS Travel by mile 420 987 122843.890109 $54665.5400 $0.4500
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Subtotal (Total Children Is Unduplicated) 452 2917 129304.894797 $388832.7700 $3.0100
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Total 3602 129665.032435 $410852.0700 $3.1700
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Number of Children (Unduplicated) With at Least One Authorization 487