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: 07-01-16 and 06-30-17 Date of Report: 08-05-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6923 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 9 9 4.722222 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 17 18 112.698412 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 26 27 117.420634 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 8 7.100000 $344.3500 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.466666 $9.9600 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 173 189 238.543652 $5140.6200 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 27.284127 $225.3700 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.955556 $24.1900 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $77.1300 $77.1300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.994444 $20.5600 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 13 12.950001 $582.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 16 19.324124 $2222.2600 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 28 29 246.321429 $12316.0700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 1.238890 $92.9300 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 42 75 172.195236 $12914.6300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 109 212 262.896647 $19717.2200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 7 4.561111 $342.0800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 46 77 97.320635 $7299.0500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 135 245 342.893472 $19030.5700 $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 66 67 253.055554 $14044.5900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 23 23 38.511111 $2888.3300 $75.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.933333 $14.0000 $15.0000
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Subtotal (Total Children Is Unduplicated) 381 975 1734.545988 $97706.6500 $56.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 21 16.472224 $82362.0000 $5000.0500
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.966666 $98.3300 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 15 16 27.003967 $1350.2000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 61 66 48.427782 $11138.4900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 162 208 523.346831 $26167.3700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 7 6.142857 $153.5700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 452 804 1767.031647 $88351.6000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 27 32 61.515077 $1537.8700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 14.133333 $706.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 1.916666 $95.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.766667 $144.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 6 6 15.633334 $781.6700 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 28 42 208.272220 $15270.5100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 51 421.185714 $10529.6400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1152 1913 21698.157114 $1084907.9700 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1183 2695 23707.016541 $237070.1900 $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 2 2 0.405555 $26.3600 $64.9900
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 4.396348 $1002.3800 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
2 2 1.638889 $373.6700 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
5 7 9.400000 $4286.4000 $456.0000
SENS -V5264 EARMOLD 11 14 24.688887 $444.4000 $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) 1199 5921 48594.956416 $1568720.6200 $32.2800
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Total 6923 50446.923038 $1666427.2700 $33.0300
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Number of Children (Unduplicated) With at Least One Authorization 1209