Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 2643 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 22 23 15.100002 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.400000 $51.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 23 24 16.500002 $51.8000 $3.1400
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 4.714286 $59.4500 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.845662 $6.9800 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 4.826615 $122.1600 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.366667 $28.2800 $77.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.366667 $6.8000 $18.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.082192 $3.7000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.655556 $305.3900 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 15 19 3.802129 $190.1200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 14 14 13.186302 $659.3100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 8.010958 $600.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 10.010958 $750.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.005479 $150.4100 $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 223 223 376.452824 $28234.0100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 165 165 290.378857 $21778.4400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 93 93 139.123278 $10434.2800 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 43 43 68.049311 $3776.7500 $55.5000
OCTF -97168 OT RE-EVAL EST PLAN CARE 45 46 12.619048 $644.2100 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.265449 $13.5500 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 14 14 5.022222 $256.3800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 25 26 12.969464 $662.1000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 26 26 4.722223 $241.0700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.455556 $23.2600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 8 2.955555 $150.8800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 15 15 5.249654 $268.0100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 83 89 25.910218 $1322.7100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 18 18 6.838888 $349.1200 $51.0500
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Subtotal (Total Children Is Unduplicated) 456 832 1005.891497 $71261.3300 $70.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.076712 $30383.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 1.122222 $56.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 6.058731 $302.9400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.344445 $309.2400 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 16 5.923518 $296.1800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 3.844444 $96.1100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 156 184 119.056347 $5952.8100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 132 146 167.372224 $4184.3100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 99 179 89.122221 $4456.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 82 78.950003 $1973.7600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 85 44.438883 $2221.9200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 53 57.216669 $1430.4200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 127 91.084127 $4554.2100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 115 118 137.805554 $3445.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 27.000000 $675.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 208 235 1439.168248 $71958.4200 $50.0000
INTR -T1013 INTERPRETER 1 1 0.122222 $6.1100 $49.9900
OCCT -97530 OT SESSION BY LICENSED OT 116 120 687.590472 $49121.4900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 101 107 672.589281 $38472.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 60 63 409.688096 $29268.1200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 42 46 247.771430 $14162.6100 $57.1600
SENS -V5060 BEHIND EAR HEARING AID
1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 1.082192 $493.4800 $456.0000
SENS -V5264 EARMOLD 6 6 4.000001 $72.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 176 188 1167.747613 $83423.9600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 35.000000 $485.8000 $13.8800
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Subtotal (Total Children Is Unduplicated) 474 1787 5502.175655 $348029.8600 $63.2500
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Total 2643 6524.567154 $419342.9800 $64.2700
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Number of Children (Unduplicated) With at Least One Authorization 653