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: 07-01-16 and 09-30-16 Date of Report: 10-26-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1795 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 2 2 0.266667 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 9.296032 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 9.562699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.194444 $9.1500 $47.0800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.744444 $7.7600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 15 3.966666 $87.0700 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.072222 $4.7000 $65.1200
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 2.266666 $106.0800 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 2.527777 $302.3100 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.677778 $133.8900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 6.005556 $300.2800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 1.983333 $148.7500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 5 4.650000 $348.7500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 24 34 31.307531 $2348.0400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 1.072223 $80.4200 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 18 19 14.505555 $1087.9100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 38 51 39.318642 $2182.1700 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 31 31 56.522222 $3136.9800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 16 16 29.000000 $2175.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 115 202 197.815059 $12507.7600 $63.2300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 8 1.714383 $8571.5000 $4999.7600
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.516666 $25.8300 $49.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 43 43 17.377288 $868.8500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 6.221429 $445.5100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.183333 $283.0500 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 54 58 277.500002 $13875.0100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 173 238 319.125397 $15956.2700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 14 18 18.105555 $452.6400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 13 32.583334 $2389.0100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 15 62.490477 $1562.2600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 387 460 2399.219851 $119960.9800 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 441 713 2848.180174 $28481.8000 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.772222 $50.1900 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 1.988888 $471.5800 $237.1100
SENS -V5264 EARMOLD 5 5 4.072221 $73.3000 $18.0000
TRAV -TRAVS Travel by mile 1 1 3.642857 $1.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 461 1587 5998.694077 $193619.4100 $32.2800
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Total 1795 6206.071835 $206127.1700 $33.2100
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Number of Children (Unduplicated) With at Least One Authorization 468