Summary Report for FSPSAs Ending During the Report Period Center: 54
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 1897 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 0.250000 $9.2500 $37.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 5.885714 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 6.135714 $9.2500 $1.5100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 28 30 14.000000 $679.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 0.655555 $30.8700 $47.0900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 8 1.617656 $105.3800 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 12 12 2.856086 $72.9100 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 4 1.894445 $88.6600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $239.2000 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 42 47 36.603694 $1830.1800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 1.644444 $123.3300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.744444 $55.8300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.900000 $67.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 1.600000 $88.8000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.095890 $7.1900 $75.0100
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 0.095890 $7.1900 $75.0100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 2 1.888889 $29.4700 $15.6000
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.177778 $8.8900 $50.0100
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Subtotal (Total Children Is Unduplicated) 95 116 67.774771 $3484.3900 $51.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 22 13.392454 $66962.0000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.522222 $26.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.555555 $27.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.716667 $171.4300 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 46 54 49.140484 $2457.0600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 319 477 383.073802 $19153.6500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 9 4.333334 $108.3400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 3.094444 $154.7200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.577778 $28.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 11.433333 $571.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.266667 $6.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 3 6.933334 $508.3600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 5.533333 $138.3300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 7 44.695238 $2234.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 62 80 331.185714 $16559.2700 $50.0000
INTR -T1013 INTERPRETER 2 2 10.142857 $507.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 518 1070 3589.218262 $35892.1700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 7.571429 $540.9000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 6 6 35.166666 $2512.2900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.428571 $310.3000 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $474.2400 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 3 1.222222 $579.6200 $474.2300
SENS -V5264 EARMOLD 1 3 1.955556 $35.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 9 14 44.157143 $3154.5900 $71.4400
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Subtotal (Total Children Is Unduplicated) 522 1777 4552.317065 $153115.4800 $33.6300
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Total 1897 4626.227550 $156609.1200 $33.8500
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Number of Children (Unduplicated) With at Least One Authorization 533