Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6718 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 45 47 58.084129 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.022223 $37.8300 $37.0000
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Subtotal (Total Children Is Unduplicated) 47 49 59.106352 $37.8300 $0.6400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 27 89.714079 $4351.1300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $102.7000 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 1.211112 $21.7000 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.211112 $25.8600 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.858601 $23.4400 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 7 3.526333 $75.9900 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 3.391934 $28.0200 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 0.855556 $7.7500 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 1.391934 $35.2300 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 1.211112 $42.3600 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.355556 $27.4300 $77.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 1.104110 $51.2500 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 0.640488 $11.8800 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 7 4.496044 $92.9800 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 5 1.333942 $60.0300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 2.467275 $283.7400 $115.0000
EXIT -EXIT EXIT ASSESSMENT 187 190 380.000000 $19000.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 26 26 25.086756 $1881.5100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 2.066667 $155.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 6.005480 $450.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 19 20 19.571688 $1467.8800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 21 21 25.594064 $1420.4700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 286 288 463.790994 $34784.3300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 44 44 69.000000 $5175.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 66 66 104.222505 $7816.6900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 375 376 634.568490 $35218.5500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 133 134 230.505480 $17287.9100 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 8.000000 $408.4000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 2.331508 $119.0200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 6.084932 $310.6300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.090411 $157.7600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 1.295890 $66.1600 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 5 1.814155 $27.2100 $15.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 13 82.263014 $4199.5300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 726 1301 2186.061222 $135392.1600 $61.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 26 28 89.368874 $446844.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.711720 $35.5900 $50.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 12 14 4.023015 $201.1500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.322222 $94.6800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 4 5 4.056164 $932.9300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 266 299 304.700253 $15235.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 2.500000 $62.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 106 135 202.361990 $10118.0900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 53.500000 $1337.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 24 36.262701 $1813.1500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.200000 $30.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 63 84.867462 $4243.3800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.500000 $62.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 87 100 138.760318 $6938.0200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.200000 $30.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.714286 $92.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 740 808 5097.990231 $254899.5700 $50.0000
INTR -T1013 INTERPRETER 127 156 414.650000 $20732.5000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 987 1538 7592.387787 $75923.8800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 31 35 177.707935 $12695.4700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 97 110 538.675397 $38482.9600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 3.968254 $226.8200 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 4 1.926027 $125.2000 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 1.114155 $127.0200 $114.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
3 4 2.056164 $937.6300 $456.0100
SENS -V5264 EARMOLD 9 10 5.481583 $98.6700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 168 184 1159.552377 $82838.4500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 18.142858 $1037.7700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 37.652381 $522.6200 $13.8800
TRAV -TRAVS Travel by mile 1185 1825 17398.271842 $7742.2300 $0.4500
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Subtotal (Total Children Is Unduplicated) 1233 5368 33381.625996 $984462.1000 $29.4900
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Total 6718 35626.793570 $1119892.0800 $31.4300
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Number of Children (Unduplicated) With at Least One Authorization 1487