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: 04-01-18 and 06-30-18 Date of Report: 08-10-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1074 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 1 1 0.333333 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 4 8.266667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 5 8.600000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 2.000000 $97.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.088889 $23.4700 $21.5500
EXIT -EXIT EXIT ASSESSMENT 3 3 141.000000 $7050.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 0.633333 $47.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 1.238890 $92.9300 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 7 1.600001 $120.0100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 2.372222 $131.6600 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 166.000000 $9213.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 3 3 6.000000 $450.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 25 41 321.933335 $17225.5500 $53.5100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 25 25 17.155556 $857.7800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 124 170 138.257145 $6912.8700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 1.205555 $30.1400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 13 2.888889 $144.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 10 7.870635 $393.5400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 2.144445 $107.2300 $50.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 4.166667 $305.5000 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 18.841270 $471.0300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 56 60 256.050797 $12802.5500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 482 728 2559.060334 $25590.6000 $10.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.127778 $8.3100 $65.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 1.428571 $102.0600 $71.4400
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Subtotal (Total Children Is Unduplicated) 491 1028 3013.197642 $57981.0400 $19.2400
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Total 1074 3343.730977 $75206.5900 $22.4900
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Number of Children (Unduplicated) With at Least One Authorization 494