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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2341 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 55 57 70.693650 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 55 57 70.693650 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 21 21 42.000000 $2100.0000 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
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) 27 27 48.000000 $2498.1500 $52.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 4 3.244444 $162.2200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 17 18 12.522223 $626.1200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.046575 $10.7200 $230.1200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 178 192 12.021924 $601.4000 $50.0200
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 12 13 0.951391 $23.7900 $25.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 25 25 26.550003 $1327.5200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 16 18 15.766666 $394.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 7 6.766667 $338.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 1.150000 $28.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 7.908333 $395.4200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 5 5 5.550000 $138.7500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 21 27.475001 $1373.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 14 14 11.149999 $278.7500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 5.142857 $128.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 55 63 1157.999999 $28950.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 473 517 2861.504757 $143075.2900 $50.0000
INTR -T1013 INTERPRETER 20 21 55.201869 $2760.1000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 667 859 4775.738888 $47757.4100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 85 94 329.859527 $23565.1900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 11 47.990475 $2745.0600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 88 99 327.183335 $23373.9500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 25.300000 $1446.1500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 3.184019 $206.9700 $65.0000
SENS -V5060 BEHIND EAR HEARING AID
1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 1.046575 $477.2500 $456.0100
SENS -V5264 EARMOLD 17 19 13.055557 $235.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 180 207 851.369048 $60821.7700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 19 20 374.714288 $5201.0300 $13.8800
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Subtotal (Total Children Is Unduplicated) 790 2257 10963.394420 $356671.4100 $32.5300
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Total 2341 11082.088070 $359169.5600 $32.4100
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Number of Children (Unduplicated) With at Least One Authorization 835