Summary Report for FSPSAs Ending During the Report Period Center: 51
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: 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 135 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 8 8 11.909523 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 2.866666 $106.0600 $37.0000
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Subtotal (Total Children Is Unduplicated) 11 11 14.776189 $106.0600 $7.1800
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.571429 $25.7100 $45.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 5.714286 $285.7200 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 9.000000 $459.4500 $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 6 6 6.000000 $306.3000 $51.0500
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Subtotal (Total Children Is Unduplicated) 22 23 24.285715 $1230.3300 $50.6600
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 5.100000 $255.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.022222 $0.5600 $24.9800
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.266667 $13.3400 $50.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 4.033333 $201.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 8.233333 $411.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.022222 $0.5600 $24.9800
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 28 28 194.293650 $9714.7000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 23 290.571429 $20758.4100 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.857143 $275.5500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 35.438094 $2531.7100 $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 25 25 206.714285 $14767.6600 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 2 2 7.690476 $284.5400 $37.0000
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Subtotal (Total Children Is Unduplicated) 80 101 758.242854 $50127.3400 $66.1100
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Total 135 797.304758 $51463.7300 $64.5500
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Number of Children (Unduplicated) With at Least One Authorization 104