Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 07-01-16 and 09-30-16 Date of Report: 10-26-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1148 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 0.266667 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 9.296032 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 6 9.562699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.744444 $7.7600 $10.4200
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 2.677778 $133.8900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 6.005556 $300.2800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 10 5.227777 $392.0800 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.405556 $30.4200 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.461111 $34.5800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 6.094444 $338.2400 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 25 38 28.622222 $1658.1700 $57.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 0.208828 $1044.0000 $4999.3300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.516666 $25.8300 $49.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 39 39 15.788399 $789.4100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 6.221429 $445.5100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.761111 $182.0600 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 52 56 276.000002 $13800.0100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 2.000000 $50.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 173 238 319.125397 $15956.2700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 14 18 18.105555 $452.6400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 4.416667 $323.8300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 2.666667 $66.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 21 26 98.677778 $4933.9000 $50.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 440 710 2837.937317 $28379.3700 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.311111 $20.2200 $65.0000
TRAV -TRAVS Travel by mile 1 1 3.642857 $1.6200 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 454 1104 3588.379784 $66571.3300 $18.5500
-------------------------------------------------------------------------------------------------------------------------------------
Total 1148 3626.564705 $68229.4900 $18.8100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 459