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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 644 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 10 10 13.966666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 4.933333 $182.5300 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 13 13 18.899999 $182.5300 $9.6600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 1.000000 $48.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 8 5.494444 $310.3800 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 2.288890 $31.7500 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 18 18 9.844443 $233.3100 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $9.0800 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 32 35 20.627777 $660.8500 $32.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.000000 $15000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.294444 $21.0800 $71.6000
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 6.183333 $1422.1600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 4 4.250000 $212.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 11 13 8.571428 $428.5800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 4 4 5.138095 $256.9000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 28.802380 $1440.1200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 32 33 43.794440 $2189.7000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 8.661111 $216.5300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.794445 $39.7300 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 13 13 18.455553 $922.7700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 5.400000 $135.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 15 16.961111 $848.0600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 15 15 18.138888 $906.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 2.816666 $70.4200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 87 87 441.059519 $22052.9800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 200 208 1024.402374 $51220.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 21 23 90.684126 $906.8400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 26.466668 $1890.7900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 6 6 36.752379 $2625.5900 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 35 38 201.885709 $14422.7300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 39.345239 $2810.8200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 6 7 29.868253 $2133.7800 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.857143 $418.4300 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 22 22 145.728569 $10410.8400 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 11 49.015872 $3501.7000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 9 9 28.228571 $2016.6400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 28 28 187.884126 $13422.4600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.450000 $6.2500 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 417 596 2480.890442 $152073.8000 $61.3000
-------------------------------------------------------------------------------------------------------------------------------------
Total 644 2520.418218 $152917.1800 $60.6700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 429