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: 07-01-17 and 09-30-17 Date of Report: 11-04-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1469 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 1 1 0.533333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.533333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 6 3.427777 $166.2400 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 28 28 18.231746 $392.8900 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.372222 $42.8000 $114.9900
EXIT -EXIT EXIT ASSESSMENT 4 4 4.250000 $212.5000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 6 5.155555 $386.6600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 11 8.449999 $633.7400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 8 4.588888 $344.1600 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 16 13.916666 $772.3700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 27 27 53.500000 $2969.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 17 34.000000 $2550.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 80 136 166.892853 $10015.6200 $60.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 2.594444 $12972.0000 $4999.9200
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.027778 $1.3900 $50.0400
AUDE -V5160 DISPENSING FEE BINAURAL 17 17 5.655556 $1300.7900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 43 50 52.754761 $2637.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 114 151 174.612697 $8730.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 5.766667 $144.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 7.000000 $350.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 6.726191 $336.3200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.766667 $69.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 5.066667 $253.3400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 5 5 20.685714 $1516.6800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 35.723810 $893.1000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 368 396 1827.321431 $91366.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 429 639 2260.530164 $22605.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 16 63.898413 $4564.9100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 21.047619 $1203.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 3 3 5.744444 $410.3800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.933333 $224.8300 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.027778 $6.3400 $228.1800
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 0.372222 $169.7200 $455.9700
SENS -V5264 EARMOLD 2 2 0.372222 $6.7000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 38.809523 $2772.5500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.714286 $326.8600 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 6.600000 $91.6100 $13.8800
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Subtotal (Total Children Is Unduplicated) 442 1332 4555.752387 $153004.4100 $33.5800
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Total 1469 4723.178573 $163020.0300 $34.5100
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Number of Children (Unduplicated) With at Least One Authorization 444