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 06-30-20 Date of Report: 07-20-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 3295 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 15 15 18.411111 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 16.333333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 18.938889 $700.7400 $37.0000
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Subtotal (Total Children Is Unduplicated) 24 24 53.683333 $700.7400 $13.0500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 7 5.409666 $262.3700 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 11 10.300000 $244.1100 $23.7000
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.350000 $17.8700 $51.0700
EXIT -EXIT EXIT ASSESSMENT 7 7 11.594444 $579.7200 $50.0000
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 2 2 1.044444 $78.3300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.561111 $31.1400 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 20.433332 $1021.6600 $50.0000
SCREEN-T1023 SCREENING 4 4 23.207143 $1160.3600 $50.0000
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Subtotal (Total Children Is Unduplicated) 35 41 76.216807 $3605.3100 $47.3000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 3.777778 $18889.0000 $5000.0300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.088889 $4.4500 $50.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 5.966667 $1372.3400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 64 73 65.557937 $3277.9000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 3 2.005556 $100.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 6 4.500000 $112.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 65 75 176.207143 $8810.3600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 151 346.713491 $17335.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 42.509524 $1062.7400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 96 123 278.597616 $13929.8700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.711111 $35.5600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.500000 $12.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 96 115 205.231745 $10261.5900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 3 3 5.655556 $282.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 13.033333 $325.8300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 17 31 147.020636 $3675.5200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 6.650000 $332.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 82 104 1206.271424 $60313.6000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 9.533333 $476.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1142 2463 22154.538349 $221545.4200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 11 93.723808 $6695.6300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 13.285714 $949.1300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 13 16 169.499999 $12109.0900 $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 17 22 289.660317 $20693.3400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.571429 $326.5800 $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) 1145 3230 25252.474847 $403138.1800 $15.9600
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Total 3295 25382.374987 $407444.2300 $16.0500
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Number of Children (Unduplicated) With at Least One Authorization 1161