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: 01-01-19 and 03-31-19 Date of Report: 05-04-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1392 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 1.200000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 12.857143 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 45 45 45.947621 $1700.0700 $37.0000
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Subtotal (Total Children Is Unduplicated) 47 48 60.004764 $1700.0700 $28.3300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 6 5.666667 $274.8400 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 2.444443 $33.9000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 15 15 5.694445 $134.9600 $23.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 11.857143 $265.6000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 3 5.000000 $375.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 10 12.649999 $948.7400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 2 0.783333 $58.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 5 7.866666 $436.6000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 6.500000 $487.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 12 12 18.500000 $1026.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 1.500000 $112.5000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 49 74 84.462696 $4565.1300 $54.0500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 6.266667 $31333.5000 $5000.0300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.922222 $46.1100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 7.683333 $1767.1600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 24 19.566666 $978.3300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 15 15 19.622221 $981.1100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 23 31.183333 $1559.1700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 40 48.428572 $2421.4400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.255556 $6.3900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 25 27 27.538891 $1376.9600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 0.977778 $24.4500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 6 6 13.055555 $957.2300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 18 56.180957 $1404.5200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 284 310 1429.841279 $71492.0200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 439 598 2438.278592 $24382.7700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 56 304.102381 $21725.0800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 6 20.804761 $1190.0300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 47 52 360.833338 $25777.9300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 25.980953 $1485.0700 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.355556 $1074.1500 $456.0100
SENS -V5264 EARMOLD 2 2 2.355556 $42.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 60 341.932546 $24427.6600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 4.504762 $62.5300 $13.8800
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Subtotal (Total Children Is Unduplicated) 462 1270 5163.671475 $214540.9800 $41.5500
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Total 1392 5308.138935 $220806.1800 $41.6000
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Number of Children (Unduplicated) With at Least One Authorization 466