Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 615 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
Screening, Eval, and Assessment, Class # 02
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 6 6 6.000000 $300.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 2 2 2.000000 $100.0000 $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) 12 12 12.000000 $603.1500 $50.2600
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 2.766667 $138.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 12 12 16.633333 $831.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 179 213 445.066667 $22253.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 136 301.642865 $15082.1900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 56 129.433333 $6471.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 126 131 262.666667 $13133.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 6.400000 $160.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 18 86.052384 $4302.6300 $50.0000
INTR -T1013 INTERPRETER 8 8 71.495240 $3574.7600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 22.142858 $1581.8800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 2 9.714285 $555.6600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 4 13.261905 $947.4400 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 14 94.623811 $6759.9300 $71.4400
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Subtotal (Total Children Is Unduplicated) 259 603 1462.900015 $75857.8200 $51.8500
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Total 615 1474.900015 $76460.9700 $51.8400
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Number of Children (Unduplicated) With at Least One Authorization 267