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: 04-01-16 and 06-30-16 Date of Report: 08-06-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1666 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
SCTT -SCTT SERVICE COORDINATOR TRAVEL 5 6 20.223810 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 6 20.223810 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.288889 $13.6000 $47.0900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 32 32 15.589682 $342.1900 $21.9500
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.238889 $28.5700 $119.6100
EXIT -EXIT EXIT ASSESSMENT 6 6 8.000000 $400.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 1.461111 $109.5800 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 9 11 11.483335 $861.2600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 25 34 29.205557 $2190.4300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.488889 $36.6700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 13 12.366667 $927.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 39 52 42.192066 $2341.6700 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 37 37 74.000000 $4107.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 14.022222 $1051.6700 $75.0000
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Subtotal (Total Children Is Unduplicated) 125 199 209.337307 $12410.1500 $59.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 11 6.027777 $30138.5000 $4999.9400
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.722222 $36.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 24 24 11.588095 $579.4000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.205556 $14.7200 $71.6300
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 1.830952 $437.9500 $239.1900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 38 49 166.984127 $8349.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 2.272223 $56.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 166 220 306.191275 $15309.6000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 15 21 23.644446 $591.1200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 14 14 36.052379 $2643.3500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 12.499999 $312.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 389 450 2277.305531 $113865.3700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 420 653 2483.629342 $24836.3100 $10.0000
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Subtotal (Total Children Is Unduplicated) 448 1461 5328.953924 $197170.9500 $37.0000
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Total 1666 5558.515041 $209581.1000 $37.7000
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Number of Children (Unduplicated) With at Least One Authorization 454