Summary Report for FSPSAs Ending During the Report Period Center: 06
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 2072 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 43 43 42.331746 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.488889 $18.0900 $37.0000
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Subtotal (Total Children Is Unduplicated) 44 44 42.820635 $18.0900 $0.4200
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $8.7500 $8.7500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.066667 $3.1200 $46.8200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $239.2000 $119.6000
EXIT -EXIT EXIT ASSESSMENT 12 12 24.000000 $1200.0000 $50.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 17 17 31.066667 $1655.2700 $53.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.060274 $5301.5000 $5000.1200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 6 6 2.233334 $111.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 14 14 12.241271 $612.0700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 2.243836 $536.7400 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 142 156 22.882292 $1144.3100 $50.0100
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 18 19 0.373579 $9.3500 $25.0300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 15 17 18.383334 $919.1700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 3.016667 $75.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 13.516667 $675.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.566667 $39.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 13 18.499999 $925.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.850000 $71.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 17 19 26.731508 $1336.5800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.450000 $11.2500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 25.142857 $628.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 65 70 1499.500001 $37487.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 368 390 2269.623818 $113481.1100 $50.0000
INTR -T1013 INTERPRETER 33 35 77.747619 $3887.3800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 586 747 4079.643189 $40796.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 82 97 320.817858 $22919.2500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 11 12 25.121428 $1436.9500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 97 104 349.457143 $24965.2100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 16 17 48.696427 $2783.4900 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 0.712329 $46.3100 $65.0100
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 4.000000 $948.4800 $237.1200
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.079452 $18.8500 $237.2600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 0.164384 $77.9700 $474.2900
SENS -V5264 EARMOLD 17 17 16.771428 $301.8800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 201 227 831.378567 $59393.7400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 12 13 204.142857 $2833.5000 $13.8800
TRAV -TRAVS Travel by mile 1 1 1.900000 $0.8500 $0.4500
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Subtotal (Total Children Is Unduplicated) 736 2011 9880.948785 $323776.7200 $32.7700
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Total 2072 9954.836087 $325450.0800 $32.6900
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Number of Children (Unduplicated) With at Least One Authorization 778