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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1344 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 2 2 3.200000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.033333 $75.2300 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 3 5.233333 $75.2300 $14.3800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 3.000000 $145.5000 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 7 2.377776 $32.9800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 22 22 6.061111 $143.6500 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.211111 $102.7500 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.855556 $30.9900 $16.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.200000 $9.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.200000 $23.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 3 3 4.577778 $228.8900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 4 1.988888 $149.1600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 6 2.055555 $154.1600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 10 6.016667 $451.2500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 10 9.233334 $512.4500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.600000 $45.0000 $75.0000
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 0.600000 $45.0000 $75.0000
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Subtotal (Total Children Is Unduplicated) 49 75 43.977776 $2295.7800 $52.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 7 6.055556 $30278.0000 $5000.0400
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.011111 $0.7900 $71.5400
AUDE -V5160 DISPENSING FEE BINAURAL 13 13 6.138889 $1411.9500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 23 21.672222 $1083.6100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.500000 $12.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 50 62 72.644446 $3632.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 18 15.033334 $751.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.422222 $10.5600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 24 22.044442 $1102.2100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 29 30 20.366667 $1018.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.166667 $29.1700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 14.425397 $1057.6700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 16.380954 $409.5300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 416 444 2401.188121 $120059.3900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 462 600 2591.594477 $25915.9400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 16 79.627781 $5688.6200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.571429 $89.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 2.142857 $153.0900 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.200000 $13.0000 $65.0000
SENS -V5264 EARMOLD 1 1 0.400000 $7.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 8.019047 $572.8800 $71.4400
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Subtotal (Total Children Is Unduplicated) 475 1266 5283.605619 $193398.2100 $36.6000
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Total 1344 5332.816728 $195769.2300 $36.7100
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Number of Children (Unduplicated) With at Least One Authorization 478