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 1045 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
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 -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.322222 $24.1700 $74.9900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 2.538889 $190.4200 $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 2 2 0.338889 $25.4200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 3.766667 $209.0500 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 22 34 19.694445 $1175.2900 $59.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 2.294444 $11472.0000 $4999.9000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.722222 $36.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 21 21 9.505555 $475.2800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 37 48 165.984127 $8299.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 2.272223 $56.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 166 219 305.857942 $15292.9400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 15 21 23.644446 $591.1200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 2.966666 $217.5100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.733333 $18.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 29 32 140.200791 $7010.0500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 419 651 2474.962675 $24749.6400 $10.0000
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Subtotal (Total Children Is Unduplicated) 435 1005 3129.144424 $68218.9900 $21.8000
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Total 1045 3169.062679 $69394.2800 $21.9000
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Number of Children (Unduplicated) With at Least One Authorization 439