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 1060 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
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Subtotal (Total Children Is Unduplicated) 6 8 18.279763 $5.2900 $0.2900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 3 1.433333 $69.5200 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.266667 $2.7800 $10.4200
EXIT -EXIT EXIT ASSESSMENT 4 4 25.911111 $1295.5600 $50.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 0.644447 $48.3500 $75.0300
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 0.644447 $35.7800 $55.5200
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 4.000000 $222.0000 $55.5000
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Subtotal (Total Children Is Unduplicated) 16 27 32.900005 $1673.9800 $50.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.002740 $13.5000 $4927.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.505556 $25.2800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 45 45 14.905393 $745.2800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 0.899207 $64.3900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.622222 $148.8300 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 50 54 117.816667 $5890.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 0.755556 $18.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 170 216 282.189684 $14109.4900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 16 21 21.433333 $535.8300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.466667 $11.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 25 29 93.119046 $4655.9700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 433 644 2409.087415 $24090.9000 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.200000 $13.0000 $65.0000
TRAV -TRAVS Travel by mile 1 1 0.005556 $0.0000 $0.4500
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Subtotal (Total Children Is Unduplicated) 449 1025 2942.009042 $50323.8700 $17.1100
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Total 1060 2993.188810 $52003.1400 $17.3700
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Number of Children (Unduplicated) With at Least One Authorization 453