Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 2475 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 8 8 41.858730 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 42.108730 $9.2500 $0.2200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 25 12.763548 $619.0400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 15 15 5.922222 $278.8800 $47.0900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 15 6.977777 $454.5300 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $22.9000 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 18 18 9.414306 $240.3400 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 6 2.333333 $109.2000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.838888 $100.3200 $119.5900
EXIT -EXIT EXIT ASSESSMENT 21 23 15.182743 $759.1300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 1.364992 $102.3700 $74.9900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.455556 $34.1700 $75.0100
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.422222 $31.6700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 1.364992 $102.3700 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.477778 $193.0200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 4 0.797260 $59.8000 $75.0000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 3 0.457534 $34.3200 $75.0100
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.844444 $43.1100 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 4 3.955556 $61.7100 $15.6000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.666667 $34.0400 $51.0500
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Subtotal (Total Children Is Unduplicated) 97 128 68.239818 $3280.8900 $48.0800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 36 50 33.458168 $167292.0000 $5000.0300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.500000 $25.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.766667 $38.3400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 7 7 5.605556 $401.4200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 2.350000 $562.1200 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 45 39.698861 $1984.9600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 342 513 441.377774 $22068.8700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 7 6.999999 $175.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 3.922222 $196.1100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 3.611111 $180.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 6.688890 $334.4500 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 4.133334 $303.0600 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.300000 $7.5000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 8 33.857141 $1692.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 466 540 3008.972248 $150448.4700 $50.0000
INTR -T1013 INTERPRETER 1 1 11.714286 $585.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 500 1077 3713.226214 $37132.2300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 7 50.328572 $3595.4700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 17 17 76.638097 $5475.0200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.666667 $38.1100 $57.1600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 3 5 2.666666 $1264.6100 $474.2300
SENS -V5264 EARMOLD 4 6 4.855556 $87.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 22 140.590479 $10043.7800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.066667 $42.5700 $13.8800
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Subtotal (Total Children Is Unduplicated) 509 2338 7595.995175 $403975.5900 $53.1800
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Total 2475 7706.343723 $407265.7200 $52.8500
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Number of Children (Unduplicated) With at Least One Authorization 520