Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6655 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 34 34 37.377780 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 0.955556 $35.3600 $37.0000
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Subtotal (Total Children Is Unduplicated) 36 36 38.333336 $35.3600 $0.9200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 26 24.389552 $1182.8900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.311111 $15.9800 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 4 1.259056 $22.5600 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 5 3.111111 $66.4200 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 4 1.259056 $15.8800 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 7 10 5.480213 $118.1000 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 4 3.111111 $25.7000 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.522222 $4.7300 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 3 1.111111 $28.1200 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 3 1.111111 $38.8600 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 3.033333 $233.9600 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.147945 $6.8700 $46.4100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 3 0.736834 $13.6700 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 5 5.644444 $116.7300 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 6 2.004261 $90.1900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 8 4.643075 $533.9600 $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 375 378 651.425632 $36154.1300 $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 3 3 3.000000 $153.1500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.169864 $212.8700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 4.139727 $211.3300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 4.060274 $207.2700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 6 1.256164 $18.8400 $15.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 10 11 12.216438 $623.6500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 2.200000 $112.3100 $51.0500
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Subtotal (Total Children Is Unduplicated) 714 1299 2070.187279 $129851.5400 $62.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 28 28 28.402459 $142012.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 4 3.270167 $163.5100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 25 27 30.627211 $1531.3500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 12.747619 $912.8600 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 5 7 2.682039 $616.8600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 274 303 310.560907 $15528.0200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 120 136 297.097010 $14854.8500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 6.285714 $157.1400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 26 38.838095 $1941.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 63 64 107.871432 $5393.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.433333 $110.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 91 152.387661 $7619.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 17.300000 $432.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 774 807 5156.634996 $257831.5300 $50.0000
INTR -T1013 INTERPRETER 124 161 412.059524 $20602.9900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1027 1511 7733.744382 $77337.3900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 47 303.242858 $21663.6700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.571429 $433.0800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 92 100 627.018265 $44794.1500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 27.428572 $1567.8100 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 3.350000 $217.7500 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 1.422070 $162.1100 $113.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
3 5 2.847945 $1298.6400 $455.9900
SENS -V5264 EARMOLD 9 12 8.192391 $147.4700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 155 161 1126.747634 $80494.7800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 56.428573 $783.2300 $13.8800
TRAV -TRAVS Travel by mile 1087 1800 18592.387961 $8273.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 1131 5320 35072.580247 $706883.5000 $20.1500
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Total 6655 37181.100862 $836770.4000 $22.5100
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Number of Children (Unduplicated) With at Least One Authorization 1195