Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 07-01-20 and 09-30-20 Date of Report: 10-15-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 214 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 11 11 11.355556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 11.355556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 2.400000 $116.4000 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.000000 $71.1000 $23.7000
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.166667 $8.5100 $51.0800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.277778 $6.2200 $22.4000
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 9 9 7.844445 $302.2400 $38.5300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.800000 $4000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $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 8 8 7.285714 $364.2900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 7 8 11.678571 $583.9300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 15.950001 $797.5100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 32 33 27.184128 $1359.2200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 2.288888 $57.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 7.000000 $350.0000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 12 13 16.350000 $817.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 18 19 12.277776 $613.8800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 23 23 23.988095 $1199.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 3.116667 $77.9200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 1.642857 $41.0700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 7.400000 $370.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7 7 45.561903 $2278.1000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 16.290477 $814.5300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 22 25 117.331746 $1173.3200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 21.304761 $1522.0100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.333333 $238.1300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 19.714286 $1408.3900 $71.4400
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Subtotal (Total Children Is Unduplicated) 151 194 368.784917 $18635.6700 $50.5300
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Total 214 387.984918 $18937.9100 $48.8100
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Number of Children (Unduplicated) With at Least One Authorization 166