Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 4558 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 28 28 34.504764 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.355556 $13.1600 $37.0000
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Subtotal (Total Children Is Unduplicated) 29 29 34.860320 $13.1600 $0.3800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 23 22.948456 $1113.0000 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.147945 $2.6500 $17.9100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.147945 $1.8700 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.147945 $3.1900 $21.5400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.147945 $6.8700 $46.4100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.147945 $2.7400 $18.5400
EXIT -EXIT EXIT ASSESSMENT 187 190 380.000000 $19000.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 4.010958 $300.8300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 20.016437 $1501.2400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 6.500000 $487.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 3 3 5.000000 $375.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 32 32 54.516437 $3025.6700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 14 14 26.000000 $1950.0000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 1.084932 $55.3800 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.030137 $103.6400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 246 300 531.852561 $28494.1200 $53.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 3.383333 $16916.5000 $4999.9500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 19 19 21.993879 $1099.6900 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 273 302 309.560907 $15478.0200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 119 134 287.311296 $14365.5700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 6.285714 $157.1400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 26 38.838095 $1941.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 63 64 107.871432 $5393.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.433333 $110.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 84 90 150.020994 $7501.0500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 17.300000 $432.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 57 59 383.733342 $19186.6600 $50.0000
INTR -T1013 INTERPRETER 122 158 406.845238 $20342.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1027 1511 7733.744382 $77337.3900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 54.285715 $3878.1700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 16 17 96.666669 $6905.8600 $71.4400
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.677778 $44.0600 $65.0000
SENS -V5264 EARMOLD 1 1 0.677778 $12.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 26 194.680957 $13908.0000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.142857 $154.6600 $13.8800
TRAV -TRAVS Travel by mile 1087 1800 18592.387961 $8273.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 1112 4229 28422.841660 $213439.6800 $7.5100
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Total 4558 28989.554541 $241946.9600 $8.3500
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Number of Children (Unduplicated) With at Least One Authorization 1125