Summary Report for FSPSAs Ending During the Report Period Center: 54
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 1976 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 0.366667 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 4 22.733333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 5 23.100000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 26 14.072223 $682.5100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.422222 $21.6800 $51.3500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.055556 $4.2900 $77.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 2.322222 $48.0200 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.055556 $2.5000 $45.0400
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.055556 $6.3900 $115.0900
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.433333 $21.6700 $50.0000
EXIT -EXIT EXIT ASSESSMENT 68 74 88.803074 $4440.1400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 4.400000 $330.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 5 4.400000 $330.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 105 120 115.019742 $5887.2000 $51.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 7.344445 $36722.5000 $5000.0400
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.250000 $12.5000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.255556 $58.7900 $230.0400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 70 75 46.998624 $2349.9500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 352 538 363.155487 $18157.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 2 0.222222 $5.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 3.866668 $193.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 5.194445 $259.7300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 14 14 13.782540 $689.1300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 9 11 55.900000 $2795.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 47 50 241.915877 $12095.8100 $50.0000
INTR -T1013 INTERPRETER 2 2 1.008219 $50.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 530 1121 3282.973828 $32829.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 28.000000 $2000.3300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 6 25.619048 $1830.2100 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.055556 $25.3500 $456.3600
SENS -V5264 EARMOLD 1 1 0.055556 $1.0000 $18.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 0.005556 $0.4000 $72.0100
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.555556 $260.5800 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 1 2 11.500000 $159.6200 $13.8800
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Subtotal (Total Children Is Unduplicated) 537 1851 4092.659183 $110497.7700 $27.0000
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Total 1976 4230.778925 $116384.9700 $27.5100
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Number of Children (Unduplicated) With at Least One Authorization 543