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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1822 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 9 9 27.419049 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.857143 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 10 33.276192 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 43 49 69.469047 $3369.2500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 4 4 3.988889 $338.4200 $84.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.711111 $122.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 27 28 47.511112 $2375.5600 $50.0000
SCREEN-T1023 SCREENING 1 1 0.777778 $38.8900 $50.0000
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.944444 $47.2200 $50.0000
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Subtotal (Total Children Is Unduplicated) 75 88 127.402381 $6370.2200 $50.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 14 18.144444 $90722.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.788889 $39.4500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.127778 $9.1500 $71.6200
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.388889 $319.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 119 137 118.459723 $5922.9900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 11 10.666667 $533.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 6 6 8.000000 $200.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 66 84 90.311111 $4515.5600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 5 6 9.394444 $469.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 101 109.976192 $5498.8200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 13 15 8.344443 $417.2200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.522222 $63.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 68 70 56.128568 $2806.4200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 4 4 1.994444 $99.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 166 170 158.999209 $7949.9800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 11 11 6.400000 $320.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 7.055554 $176.3900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 0.238889 $11.9500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 41 43 274.052381 $13702.6200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 3.714286 $185.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 509 996 3475.018245 $34750.1800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 8 9 50.247619 $3589.6800 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 10.266667 $733.4500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 12 13 70.000001 $5000.8100 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 0.188889 $13.5000 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.922222 $420.5200 $455.9900
SENS -V5264 EARMOLD 1 1 0.922222 $16.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 14 80.388889 $5742.9800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 5.044444 $360.3700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 11.142857 $796.0500 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.571429 $21.1400 $37.0000
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Subtotal (Total Children Is Unduplicated) 526 1724 4591.421617 $185408.8000 $40.3800
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Total 1822 4752.100190 $191779.0200 $40.3600
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Number of Children (Unduplicated) With at Least One Authorization 549