Summary Report for FSPSAs Ending During the Report Period Center: 53
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 1617 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 1.000000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 4 18.609523 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 5 19.609523 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 6.366667 $308.7900 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 7 1.622222 $22.5000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 19 19 7.283334 $172.6200 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $16.7000 $16.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.800000 $81.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.800000 $207.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 4.000000 $200.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 20 10.461111 $784.5800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 24 37 21.461111 $1609.5800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 10 15 9.700001 $727.5100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 14 24 18.522222 $1027.9800 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 30.000000 $1665.0000 $55.5000
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Subtotal (Total Children Is Unduplicated) 67 142 115.016668 $6908.1000 $60.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 9.388890 $46945.0000 $5000.0600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.488889 $74.4500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.444444 $31.8200 $71.6000
AUDE -V5160 DISPENSING FEE BINAURAL 14 14 8.233334 $1893.6800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 19 20 11.138889 $556.9500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 110 141 155.549999 $7777.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.605556 $15.1400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 27 20.511111 $1025.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 14 12.427778 $621.3900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 21 21 21.816668 $1090.8400 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 10 20.782540 $1523.7700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 32.984127 $824.6000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 432 489 2187.557131 $109377.8600 $50.0000
INTR -T1013 INTERPRETER 1 1 1.233333 $61.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 447 683 2382.512694 $23825.1300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 17.742859 $1267.5500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 7.428571 $424.9200 $57.2000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.311111 $20.2200 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.977778 $445.8800 $456.0100
SENS -V5264 EARMOLD 3 3 2.600000 $46.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 16.304762 $1164.8100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.428571 $5.9500 $13.8800
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Subtotal (Total Children Is Unduplicated) 466 1470 4914.969035 $199489.9600 $40.5900
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Total 1617 5049.595226 $206398.0600 $40.8700
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Number of Children (Unduplicated) With at Least One Authorization 469