Summary Report for FSPSAs Ending During the Report Period Center: 07
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 1051 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 21 23 408.165873 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 23 408.165873 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.191781 $4.1300 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 3.365906 $27.8000 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 1.199239 $30.3500 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.191781 $6.7100 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.358448 $104.7800 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.166667 $54.1600 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 1.199239 $22.2500 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.166667 $24.1300 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.542085 $24.3900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.166667 $134.1700 $115.0000
EXIT -EXIT EXIT ASSESSMENT 84 84 65.467047 $3273.3700 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 7 7 0.517808 $28.7400 $55.5100
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 0.210959 $15.8300 $75.0100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.505556 $25.8100 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.087671 $4.4800 $51.0700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 5.788889 $295.5200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 4 4 2.261111 $115.4300 $51.0500
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Subtotal (Total Children Is Unduplicated) 111 134 88.387521 $4294.1500 $48.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 2.655556 $132.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.166667 $498.3400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 126 139 112.921146 $5646.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 3 1.938890 $48.4800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 218 382 906.058900 $45302.9600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 3.300000 $82.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 13 40.876192 $2043.8200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 9.857143 $246.4300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 4.866666 $243.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 30 79.152381 $3957.6200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.300000 $132.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 186 210 1205.823809 $60291.2000 $50.0000
INTR -T1013 INTERPRETER 7 9 56.000000 $2800.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 10 61.999999 $4429.2900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 51.857142 $3704.6800 $71.4400
SENS -V5060 BEHIND EAR HEARING AID
1 1 1.166667 $266.0100 $228.0100
SENS -V5264 EARMOLD 1 1 1.166667 $21.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 35 36 192.928570 $13782.8000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 9.571429 $132.8500 $13.8800
TRAV -TRAVS Travel by mile 32 38 266.933335 $118.7900 $0.4500
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Subtotal (Total Children Is Unduplicated) 453 894 3017.541159 $148881.4000 $49.3400
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Total 1051 3514.094553 $153175.5400 $43.5900
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Number of Children (Unduplicated) With at Least One Authorization 518