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: 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 2971 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 2 2 6.890476 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 6.890476 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 34 35 6.893302 $334.3300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.230137 $4.1200 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $21.3500 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.230137 $15.5100 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.186301 $25.5600 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.230137 $10.1600 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.230137 $31.1300 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.133333 $10.2800 $77.1100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.230137 $4.2700 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $20.6800 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 10.571429 $475.7100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 10.971429 $1261.7100 $115.0000
EXIT -EXIT EXIT ASSESSMENT 64 64 151.337118 $7566.8600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 2.016437 $151.2400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 7 7 8.350684 $463.4600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 104 104 91.804089 $6885.3800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 59 59 68.135606 $5110.2100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 120 120 116.821895 $6483.6700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 71 71 81.653415 $6124.0400 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 1.529908 $78.1100 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 18 3.543150 $180.8800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 1.733072 $88.4700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 1.005556 $51.3400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 0.854794 $43.6400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 21 22 13.106499 $669.0900 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.485693 $24.8000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 5 6 0.650000 $33.1800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 32 32 12.003655 $612.7900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 13 13 2.304109 $117.6300 $51.0500
VISD -99202 VISION EVAL DIAG (SIMPLE) 1 1 0.186301 $6.7000 $35.9800
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.147945 $7.4000 $49.9800
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Subtotal (Total Children Is Unduplicated) 308 602 599.759662 $37373.2100 $62.3100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 37 38 7.004565 $35022.5000 $4999.9500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.060274 $13.8700 $230.1000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 63 65 30.880239 $1544.0100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 202 230 430.569043 $21528.4300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 3.533333 $88.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 87 130.016668 $6500.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 21 32.949999 $1647.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 151 156 261.716662 $13085.8100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 6.883333 $172.0800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 7 7 126.428573 $3160.7100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 231 237 1510.104781 $75505.2100 $50.0000
INTR -T1013 INTERPRETER 28 44 41.826146 $2091.3100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 271 398 1584.429494 $15844.2800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 62 65 378.695248 $27053.9600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 15.214285 $870.2600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 56 57 384.146709 $27443.4300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 9.895238 $565.6200 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.060274 $13.7500 $228.1000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
3 3 10.785127 $4918.0100 $456.0000
SENS -V5264 EARMOLD 4 4 11.272799 $202.9100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 85 567.214292 $40521.7800 $71.4400
TRAV -TRAVS Travel by mile 371 859 135003.421257 $60076.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 405 2367 140549.241672 $337924.4300 $2.4000
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Total 2971 141155.891810 $375297.6400 $2.6600
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Number of Children (Unduplicated) With at Least One Authorization 427