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: 04-01-21 and 06-30-21 Date of Report: 07-15-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 865 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 1 1 1.033333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 2.133333 $78.9300 $37.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.166666 $78.9300 $24.9300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 3.444444 $167.0500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.011111 $0.2600 $23.4600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 7 1.961111 $27.2000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 31 31 15.477779 $366.8300 $23.7000
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Subtotal (Total Children Is Unduplicated) 44 44 21.894445 $617.8300 $28.2200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.444444 $2222.0000 $4999.5000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.966667 $140.8400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 5.227777 $1202.3700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 8 7.005556 $350.2800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 12 12 12.000000 $600.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 3.638889 $181.9500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 5 5 15.726984 $786.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 26 26.555555 $1327.7800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 35 35 40.955555 $2047.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 5.611111 $280.5600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 14 14 30.634126 $1531.7100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 17 21.738889 $1086.9500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 26 28 39.065080 $1953.2600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 10 9.350000 $233.7500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 70 71 371.826181 $18591.3200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 199 214 1012.299982 $50614.9700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 98 120 307.616665 $3076.1700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 23 57.315873 $4094.6500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 11 12 48.366667 $3455.3100 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 7 7 21.571427 $1541.0500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 33 36 124.783331 $8914.5300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 11 13 59.311111 $4237.1800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 6 7 33.804761 $2415.0100 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 10 11 30.223809 $2159.2000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 23 26 125.299998 $8951.4400 $71.4400
SENS -V5264 EARMOLD 3 3 3.477777 $62.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 21 24 71.715873 $5123.3900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 9 9 59.238095 $4231.9700 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 10 49.965081 $3569.5100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 48 54 286.366665 $20458.0600 $71.4400
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Subtotal (Total Children Is Unduplicated) 449 819 2887.103929 $155591.9000 $53.8900
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Total 865 2912.165040 $156288.6600 $53.6700
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Number of Children (Unduplicated) With at Least One Authorization 452