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: 04-01-19 and 06-30-19 Date of Report: 07-21-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1355 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 5 5 4.419047 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 2.266667 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 9 9 24.033334 $889.2400 $37.0000
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Subtotal (Total Children Is Unduplicated) 15 15 30.719048 $889.2400 $28.9500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 2.227778 $108.0500 $48.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.655556 $22.9600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 24 24 9.744442 $230.9400 $23.7000
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.388889 $19.8600 $51.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.311111 $14.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.311111 $35.7800 $115.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 6 6.072222 $455.4200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 3.833333 $287.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 4 2.655556 $199.1700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 2.416667 $134.1300 $55.5000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $444.0000 $55.5000
SCREEN-T1023 SCREENING 2 2 4.500000 $225.0000 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 47 59 46.116665 $2427.8500 $52.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 5.566667 $27833.5000 $5000.0300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.155556 $7.7800 $50.0100
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 7.066667 $1625.3400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 24 29 17.882539 $894.1300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 25 27 38.526985 $1926.3500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 23 36.522223 $1826.1200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 29 31 34.005556 $1700.2800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 23 24 24.381746 $1219.0900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.277778 $81.9500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 8 9.255556 $678.6200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 11 50.755553 $1268.9000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 324 352 1703.034934 $85151.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 462 615 2477.424625 $24774.2200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 33 138.235713 $9875.5400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 6.200000 $354.6400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 41 43 226.490481 $16180.4800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.571429 $204.1400 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.311111 $20.2200 $65.0000
SENS -V5264 EARMOLD 1 1 0.622222 $11.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 56 199.610321 $14260.1300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 13.142858 $182.4200 $13.8800
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Subtotal (Total Children Is Unduplicated) 477 1281 4996.040520 $190076.6800 $38.0500
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Total 1355 5072.876233 $193393.7700 $38.1200
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Number of Children (Unduplicated) With at Least One Authorization 482