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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2567 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 56 56 110.504762 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 56 56 110.504762 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.666667 $30.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.866667 $444.6700 $115.0000
EXIT -EXIT EXIT ASSESSMENT 44 44 84.057534 $4202.8800 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 48 49 89.590868 $4728.6000 $52.7800
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 4.333334 $216.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 14 14 13.444445 $672.2300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $690.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 169 181 20.631020 $1031.7900 $50.0100
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 1.394843 $34.8800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 20 22 21.259524 $1062.9800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 11 11 15.397620 $384.9400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 10.450000 $522.5000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 4.359524 $108.9900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 6.933333 $346.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.116667 $27.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 18 18.276190 $913.8100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 12.640477 $316.0200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 59 62 1298.857142 $32471.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 582 644 3797.619029 $189881.0400 $50.0000
INTR -T1013 INTERPRETER 21 22 81.999999 $4100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 779 965 5739.219030 $57392.2000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 107 116 401.303565 $28669.1600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 16 19 69.269049 $3962.2000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 91 103 374.292854 $26739.5100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 4.450000 $254.3600 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.364384 $23.6900 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.866667 $425.6100 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.000000 $1368.0000 $456.0000
SENS -V5264 EARMOLD 17 17 15.022223 $270.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 192 208 864.490486 $61759.2100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 26.857143 $372.7800 $13.8800
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Subtotal (Total Children Is Unduplicated) 910 2462 12813.848548 $414474.9500 $32.3500
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Total 2567 13013.944178 $419203.5400 $32.2100
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Number of Children (Unduplicated) With at Least One Authorization 964