Summary Report for FSPSAs Initiated During the Report Period Center: 06
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 2256 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 42 42 58.799207 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 58.799207 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.145205 $16.7000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 24 24 48.000000 $2400.0000 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $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) 28 28 52.145205 $2620.9000 $50.2600
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 1.866667 $93.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 15 16 14.333335 $716.6800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.205479 $277.2700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 173 181 9.631760 $481.8900 $50.0300
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 10 11 0.201391 $5.0400 $25.0300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 28 28 33.872223 $1693.6200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 3.283334 $82.0900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 14.455557 $722.7900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.066667 $126.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 16.383332 $819.1600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 4 2.450001 $61.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 24 25 32.851588 $1642.5800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 6.216667 $155.4200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 47.428571 $1185.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 42 1156.142854 $28903.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 474 507 3203.961935 $160198.0000 $50.0000
INTR -T1013 INTERPRETER 12 15 57.000000 $2850.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 676 860 5281.865931 $52818.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 95 110 420.704761 $30055.1600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 19.464285 $1113.3600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 87 96 383.590476 $27403.6800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 9.928572 $567.5200 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 5 2.787671 $181.2000 $65.0000
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.145205 $33.1100 $227.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 1.205479 $549.7100 $456.0100
SENS -V5264 EARMOLD 13 14 11.000002 $198.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 191 211 941.294047 $67246.0100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 4 12.142857 $168.5400 $13.8800
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Subtotal (Total Children Is Unduplicated) 755 2186 11690.480647 $380349.9700 $32.5400
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Total 2256 11801.425059 $382970.8700 $32.4500
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Number of Children (Unduplicated) With at Least One Authorization 794