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: 04-01-19 and 06-30-19 Date of Report: 07-21-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 911 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 2.977777 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 8.414286 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 3.233333 $119.6300 $37.0000
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Subtotal (Total Children Is Unduplicated) 8 8 14.625396 $119.6300 $8.1800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 6.000000 $291.0000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.277778 $6.5800 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.255556 $21.6900 $84.8500
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 3.900000 $292.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 5.566666 $417.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.166667 $12.5000 $75.0100
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 0.450000 $24.9800 $55.5000
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Subtotal (Total Children Is Unduplicated) 15 23 17.616667 $1116.7400 $63.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.255556 $288.7900 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 29 18.215873 $910.8000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 39 46 40.892857 $2044.6500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 21 21.216667 $1060.8400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 28 34.700002 $1735.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.277778 $6.9500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 32 33 32.687300 $1634.3600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.666667 $41.6700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 4.100000 $300.6100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 12.857145 $321.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 34 36 138.532538 $6926.6300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 492 660 2415.819028 $24158.2000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 3.885714 $277.5900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.428571 $310.5200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1 1 1.285714 $91.8500 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.194444 $12.6400 $64.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 7 51.590476 $3685.6300 $71.4400
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Subtotal (Total Children Is Unduplicated) 495 880 2785.606330 $48808.1300 $17.5200
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Total 911 2817.848393 $50044.5100 $17.7600
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Number of Children (Unduplicated) With at Least One Authorization 498