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: 07-01-20 and 09-30-20 Date of Report: 10-15-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 974 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 7 7 7.405555 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7 7 7.405555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 4.683333 $227.1400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 20 20 10.494445 $248.7200 $23.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.455556 $65.5000 $45.0000
SCREEN-T1023 SCREENING 1 1 0.255556 $12.7800 $50.0100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 29 30 17.888890 $610.6300 $34.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 4.288889 $21444.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 5.288889 $1216.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 5.285714 $264.2900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 7 7 6.285714 $314.2900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 13.295237 $664.7600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 36 36 40.483332 $2024.1600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 17 17 23.411905 $1170.6000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.533333 $13.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 12.044445 $602.2300 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 6 6 7.916667 $395.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 31 55.963492 $2798.1700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 15 15 13.150001 $657.5100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.694444 $117.3600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 4 20.695237 $1034.7600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 216 905.333331 $45266.6900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 82 93 421.757145 $21087.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 259 311 1102.855550 $11028.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 40 179.561904 $12827.9100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 5.133333 $366.7200 $71.4400
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 4.142857 $236.9700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 5.857142 $418.4400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 16 17 79.323809 $5666.9000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 28 28 173.247618 $12376.8200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 6 6 43.204761 $3086.5500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.285714 $473.6100 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.466667 $312.4800 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 11 12 71.380951 $5099.4500 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.046575 $21.2500 $456.2400
SENS -V5264 EARMOLD 1 1 0.093151 $1.6800 $18.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 24 116.771428 $8342.1600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 10 11 66.752380 $4768.7800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 16 16 94.366667 $6741.5400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.866667 $39.7900 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 7.142857 $264.2900 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 426 937 3508.927806 $171246.6900 $48.8000
-------------------------------------------------------------------------------------------------------------------------------------
Total 974 3534.222251 $171857.3200 $48.6300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 435