Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 01-01-16 and 03-31-16 Date of Report: 05-12-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1681 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.142857 $5.2900 $37.0100
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 18.136906 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 2 0.714285 $26.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 6 10 18.994048 $31.7200 $1.6700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 3 1.433333 $69.5200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.316667 $14.9100 $47.0900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.266667 $2.7800 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 5 1.183334 $25.9800 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.944444 $61.5200 $65.1400
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 1.761112 $82.4200 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.438890 $172.1000 $119.6100
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 25.911111 $1295.5600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 2.883333 $216.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 3.688889 $276.6700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 20 31 17.007082 $1275.5600 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.400000 $180.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 24 24 19.755557 $1481.6800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 43 56 38.629305 $2143.9500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 37 38 62.321839 $3458.8700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 12 12 16.788812 $1259.1600 $75.0000
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.177778 $9.0800 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.400000 $20.4200 $51.0500
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Subtotal (Total Children Is Unduplicated) 111 199 199.308153 $12146.4200 $60.9400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 1.747184 $8735.5000 $4999.7600
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.505556 $25.2800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 50 50 16.922060 $846.1200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 0.910318 $65.1900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.622222 $148.8300 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 51 55 119.316667 $5965.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 0.755556 $18.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 171 218 286.923017 $14346.1600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 16 21 21.433333 $535.8300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 1.409524 $103.3500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 45.347621 $1133.6900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 398 439 2171.559099 $108578.0500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 433 644 2409.087415 $24090.9000 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.755556 $49.1100 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.955556 $226.5900 $237.1300
SENS -V5264 EARMOLD 4 4 1.838890 $33.1000 $18.0000
TRAV -TRAVS Travel by mile 1 1 0.005556 $0.0000 $0.4500
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Subtotal (Total Children Is Unduplicated) 455 1472 5080.095130 $164902.4300 $32.4600
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Total 1681 5298.397331 $177080.5600 $33.4200
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Number of Children (Unduplicated) With at Least One Authorization 462