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 2141 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 26 27 4.875950 $236.4900 $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 -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 -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.230137 $4.2700 $18.5500
EXIT -EXIT EXIT ASSESSMENT 64 64 151.337118 $7566.8600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 4.005479 $222.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 8.038353 $602.8900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 8 8 10.016437 $751.2400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 24 24 24.065748 $1335.6600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 28 28 36.547942 $2741.1100 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 0.399696 $20.4000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 0.524353 $26.7700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.443836 $22.6600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.557686 $28.4700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.177778 $9.0800 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 2.196424 $112.1300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 0.380822 $19.4400 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.147945 $7.4000 $49.9800
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Subtotal (Total Children Is Unduplicated) 151 196 251.044030 $13948.5200 $55.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 0.468493 $2342.5000 $5000.0700
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 46 46 298.290480 $14914.5000 $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 11 11 57.623812 $4116.6400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 44.142858 $3153.5500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 12 68.142858 $4868.1100 $71.4400
TRAV -TRAVS Travel by mile 371 859 135003.421257 $60076.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 386 1943 137997.088282 $152041.6200 $1.1000
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Total 2141 138255.022788 $165990.1400 $1.2000
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Number of Children (Unduplicated) With at Least One Authorization 410