Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 04-01-17 and 06-30-17 Date of Report: 08-05-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1610 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 3 3 1.466666 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 11.085714 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 12.552380 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.505556 $24.5200 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.294444 $6.2900 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 33 33 14.822219 $319.4100 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.122222 $5.5000 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.122222 $14.0500 $114.9800
EXIT -EXIT EXIT ASSESSMENT 8 9 10.016667 $500.8400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 0.383334 $28.7600 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 6 3.294445 $247.0900 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 18 33 18.511111 $1388.3300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 6 3.550000 $266.2500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 19 32 15.899999 $1192.4900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 30 56 33.838889 $1878.0600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 158.285714 $8784.8600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 5.000000 $375.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 81 196 268.646822 $15331.4400 $57.0700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.594445 $7972.5000 $5000.1700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 8.142857 $407.1500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 15 15 4.633335 $1065.7100 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 50 59 64.624603 $3231.2300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 151 207 199.453871 $9972.7100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 2.787301 $69.6800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.411111 $20.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.422222 $21.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 1.566667 $78.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 13 31.425395 $2304.1100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 16 65.061904 $1626.5500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 410 440 1939.961904 $96998.1000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 447 623 2159.278471 $21592.7900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 5.371429 $383.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 8.028572 $459.2300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 2 2 3.238096 $231.3300 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.122222 $7.9400 $64.9900
SENS -V5264 EARMOLD 1 1 0.122222 $2.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 10.133333 $723.9200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.666667 $23.1300 $13.8800
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Subtotal (Total Children Is Unduplicated) 468 1407 4509.046627 $147217.0000 $32.6500
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Total 1610 4790.245829 $162548.4400 $33.9300
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Number of Children (Unduplicated) With at Least One Authorization 479