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 1650 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 -92555 SPEECH AUD THRESHOLD (DETECTION) 8 8 2.027778 $25.5700 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 20 20 5.794446 $124.8700 $21.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.144445 $6.5000 $45.0200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.144445 $16.6200 $115.0400
EXIT -EXIT EXIT ASSESSMENT 3 3 141.000000 $7050.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 7 3.044445 $228.3400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 20 4.438890 $332.9300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 11 16 6.400003 $480.0200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 18 8.116666 $450.4700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 20 20 196.000000 $10878.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 20 40.000000 $3000.0000 $75.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.294444 $15.0300 $51.0400
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Subtotal (Total Children Is Unduplicated) 72 142 415.405562 $23155.3500 $55.7400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 5.188889 $25944.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.016667 $0.8400 $50.1000
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 3.411111 $784.5500 $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 8 9 9.555556 $700.6200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 18 66.615871 $1665.4000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 445 489 2216.877796 $110843.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 482 728 2559.060334 $25590.6000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 8 53.761905 $3840.7500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 18.085715 $1034.5000 $57.2000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.127778 $8.3100 $65.0100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.033333 $15.1800 $455.5500
SENS -V5264 EARMOLD 2 2 0.288889 $5.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 2.857142 $204.1200 $71.4400
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Subtotal (Total Children Is Unduplicated) 495 1503 5106.403211 $179109.4100 $35.0800
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Total 1650 5530.408773 $202264.7600 $36.5700
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Number of Children (Unduplicated) With at Least One Authorization 497