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: 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 1451 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 1.000000 $37.0000 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 3 3 1.400000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 6 12.595238 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 10 10 14.995238 $37.0000 $2.4700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 1.327778 $64.4000 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.172222 $3.3100 $19.2000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 46 47 35.716667 $783.9800 $21.9500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $65.1400 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.366667 $9.3600 $25.5300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $119.6000 $119.6000
EXIT -EXIT EXIT ASSESSMENT 6 6 126.071429 $6303.5700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.227778 $17.0900 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 9 4.966666 $372.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 23 39 19.950001 $1496.2600 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.216667 $16.2500 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 17 16.469841 $1235.2400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 27 44 46.750795 $2594.6700 $55.5000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 3.000000 $225.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 18 18 24.961904 $1385.3900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 4 4 4.511111 $338.3300 $75.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 96 193 286.709526 $15030.0800 $52.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.533333 $7666.5000 $4999.8900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.522222 $26.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 3.577777 $178.8900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 20 20 7.555556 $1807.3000 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 38 46 34.294444 $1714.7200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 3.142857 $78.5700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 118 152 191.692858 $9584.6500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 0.755555 $18.8900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 4.533334 $226.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 3.133334 $156.6700 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 9 29.264287 $2145.6700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 13 43.095237 $1077.3800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 388 414 2227.335728 $111366.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 410 569 2449.523826 $24495.2300 $10.0000
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 1.744444 $827.2600 $474.2300
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 428 1248 5002.704792 $161389.2600 $32.2600
-------------------------------------------------------------------------------------------------------------------------------------
Total 1451 5304.409556 $176456.3400 $33.2700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 436