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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 833 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 0.733333 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 4.000000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 12.138889 $449.1400 $37.0000
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Subtotal (Total Children Is Unduplicated) 9 9 16.872222 $449.1400 $26.6200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.488889 $23.7100 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 5.088889 $120.6100 $23.7000
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.350000 $17.8700 $51.0700
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 2 0.833334 $62.5100 $75.0100
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.483333 $36.2500 $74.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.483333 $36.2500 $74.9900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
SCREEN-T1023 SCREENING 1 1 3.785714 $189.2900 $50.0000
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Subtotal (Total Children Is Unduplicated) 12 14 13.513492 $597.4800 $44.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.088889 $4.4500 $50.0100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.277778 $523.8900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 22 26 25.655556 $1282.7800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 23 25 32.861112 $1643.0600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 29 30 38.600000 $1930.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 37 70.336508 $3516.8300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 23 23 23.894443 $1194.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 4.888889 $122.2200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 7 5.873016 $146.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 22 23 94.504761 $4725.2400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 456 621 2510.266667 $25102.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 5.457143 $389.8600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 2 8.266667 $590.5700 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.377778 $24.5600 $65.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 6 44.938094 $3210.3800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 4.285714 $59.4900 $13.8800
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Subtotal (Total Children Is Unduplicated) 462 810 2873.573015 $49467.5300 $17.2100
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Total 833 2903.958729 $50514.1500 $17.3900
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Number of Children (Unduplicated) With at Least One Authorization 467