Summary Report for FSPSAs Initiated During the Report Period Center: 51
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 151 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 6 6 11.777778 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 5.933334 $219.5400 $37.0000
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Subtotal (Total Children Is Unduplicated) 8 8 17.711112 $219.5400 $12.4000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 26.000000 $1170.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 7 7 7.000000 $350.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 15.000000 $765.7500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $204.2000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $97.8800 $48.9400
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Subtotal (Total Children Is Unduplicated) 32 33 58.000000 $2792.0300 $48.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 5.000000 $25000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 3.700000 $185.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.011111 $25.2800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.700000 $135.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 5.533334 $276.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 2.266667 $113.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.011111 $25.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 27 29 242.071427 $12103.5700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 22 258.285716 $18451.9200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 9 57.285714 $4092.5000 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $912.0000 $456.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 34 233.857142 $16706.7500 $71.4400
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Subtotal (Total Children Is Unduplicated) 88 110 814.722222 $78027.3000 $95.7700
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Total 151 890.433334 $81038.8700 $91.0100
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Number of Children (Unduplicated) With at Least One Authorization 108