Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 1982 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 0.355556 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 22.428572 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 22.784128 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 30 28.393379 $1377.0800 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.455556 $112.2700 $77.1300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 2.600000 $53.7700 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.455556 $20.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.455556 $52.3900 $115.0100
EXIT -EXIT EXIT ASSESSMENT 58 63 90.756347 $4537.8100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.711111 $53.3300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 3.466667 $260.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 4.177778 $313.3400 $75.0000
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Subtotal (Total Children Is Unduplicated) 95 108 132.471950 $6780.4900 $51.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 11 13.188889 $65944.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 0.716667 $35.8400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.500000 $115.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 79 84 133.158515 $6657.9400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 366 544 476.244985 $23812.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.633333 $40.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 7.244445 $362.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 3.222222 $161.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 20 28.155554 $1407.7700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 5.400000 $135.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 7 44.866666 $2243.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 52 55 350.377782 $17518.9100 $50.0000
INTR -T1013 INTERPRETER 2 2 1.008219 $50.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 563 1106 3964.648451 $39646.4800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 44.257144 $3161.7300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 5 7 26.019048 $1858.7900 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.455556 $207.7500 $456.0400
SENS -V5264 EARMOLD 1 1 0.455556 $8.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 6.714286 $479.6700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.166667 $43.9500 $13.8800
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Subtotal (Total Children Is Unduplicated) 575 1871 5112.433985 $163916.6800 $32.0600
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Total 1982 5267.690063 $170697.1700 $32.4000
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Number of Children (Unduplicated) With at Least One Authorization 589