Summary Report for FSPSAs Initiated During the Report Period Center: 54
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: 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 1999 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 4 4 8.980953 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 13.190476 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 22.171429 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 42 49 37.383334 $1813.0900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 4.472222 $252.6300 $56.4900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 4.377778 $371.4100 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.344444 $17.5900 $51.0600
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.311111 $104.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 57 58 95.965862 $4798.3000 $50.0000
SCREEN-T1023 SCREENING 1 1 1.022222 $51.1100 $50.0000
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.505556 $25.2800 $50.0000
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Subtotal (Total Children Is Unduplicated) 109 123 146.382529 $7433.4200 $50.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 23 28.777779 $143889.5000 $5000.0200
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.194521 $9.7300 $49.9900
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.183333 $13.1300 $71.6000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 2.411111 $554.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 122 131 119.104121 $5955.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.005556 $25.1400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 78 86 106.730157 $5336.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 106 110 94.672219 $4733.6000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.200000 $5.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 91 97 84.344442 $4217.2100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 158 160 122.173015 $6108.6500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 3.061111 $76.5300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 66 70 358.811116 $17940.5500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 619 1133 4029.864304 $40298.6300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 80.395238 $5743.4400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.822222 $104.2300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 8 10 75.507938 $5394.2900 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.777777 $810.6300 $455.9800
SENS -V5264 EARMOLD 2 2 1.777777 $32.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 21 99.404761 $7101.4700 $71.4400
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Subtotal (Total Children Is Unduplicated) 625 1870 5212.218498 $248349.9800 $47.6500
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Total 1999 5380.772456 $255783.4000 $47.5400
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Number of Children (Unduplicated) With at Least One Authorization 648