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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1051 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 0.888889 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 14.722222 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 8 15.611111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.100000 $2.2000 $21.9500
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.277778 $33.2200 $119.6100
EXIT -EXIT EXIT ASSESSMENT 5 5 5.238096 $261.9100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 2.705555 $202.9100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 4.944443 $370.8200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.344444 $25.8300 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 22 10.022221 $556.2300 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 1.511111 $83.8700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.011111 $0.8300 $74.9300
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Subtotal (Total Children Is Unduplicated) 34 52 25.154759 $1537.8200 $61.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 4 3.233334 $16167.0000 $5000.1000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.722222 $36.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 14 14 2.905557 $145.2900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.066667 $255.1500 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 40 28.493653 $1424.6900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 3.309524 $82.7400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 170 213 258.530951 $12926.5500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 15 22 13.888887 $347.2200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 4.819047 $120.4800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 30 32 157.996032 $7899.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 438 654 2519.633348 $25196.3200 $10.0000
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Subtotal (Total Children Is Unduplicated) 446 991 2996.599222 $64701.3200 $21.5900
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Total 1051 3037.365092 $66239.1400 $21.8100
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Number of Children (Unduplicated) With at Least One Authorization 451