Summary Report for FSPSAs Ending During the Report Period Center: 01
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 4137 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 50 51 177.637301 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 11.859883 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 51 53 189.497184 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 17 8.819102 $427.7300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.032877 $1.5500 $47.1200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $19.2000 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $10.4200 $10.4200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.188889 $4.8200 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.123288 $5.7700 $46.8000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 142 146 290.066667 $14503.3400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.002740 $111.1500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 35 35 59.500000 $4462.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 19.000000 $1425.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 15 15 27.500000 $2062.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 62 62 101.802152 $5650.0200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 15 23.505479 $1762.9100 $75.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 5.400000 $84.2400 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.181888 $111.3900 $51.0500
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Subtotal (Total Children Is Unduplicated) 252 320 552.128561 $31343.9900 $56.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 4.074581 $20372.5000 $4999.9000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 13 14 20.294443 $1014.7200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.178083 $42.6000 $239.2200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 202 224 214.254400 $10712.7100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 3.883333 $97.0800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 123 180 309.276071 $15463.7900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 4.000001 $100.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 24 97.173017 $4858.6500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 32 89.899621 $4494.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 58 89.507937 $4475.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 13.761905 $344.0500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 67 71 410.238094 $20511.8900 $50.0000
INTR -T1013 INTERPRETER 80 86 318.084245 $15904.2200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 933 1398 6349.934866 $63499.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 22.571428 $1612.5000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 8 10 64.971428 $4641.5600 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 2.000000 $130.0000 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 2.000000 $237.1200 $118.5600
SENS -V5060 BEHIND EAR HEARING AID
1 1 2.000000 $474.2400 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 1 1 0.123288 $58.4700 $474.2900
SENS -V5264 EARMOLD 3 3 3.822222 $68.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 37 218.066668 $15578.6800 $71.4400
TRAV -TRAVS Travel by mile 1078 1600 21080.837944 $9380.9700 $0.4500
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Subtotal (Total Children Is Unduplicated) 1112 3764 29320.953575 $194074.2600 $6.6200
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Total 4137 30062.579320 $225418.2500 $7.5000
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Number of Children (Unduplicated) With at Least One Authorization 1203