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: 07-01-21 and 09-30-21 Date of Report: 10-13-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 296 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 4 4 4.788890 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 4.788890 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 3.027778 $146.8500 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $47.4000 $23.7000
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Subtotal (Total Children Is Unduplicated) 6 6 5.027778 $194.2500 $38.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 27.428571 $1371.4300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.083333 $249.1600 $229.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 12 10.750000 $537.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 6 7 4.688889 $234.4500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 5.383333 $269.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 7 7 11.306349 $565.3200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.844444 $21.1100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 18 21.083332 $1054.1600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 41 41 44.482540 $2224.1300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 7.144445 $178.6100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 9.199999 $460.0000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 14 14 24.001587 $1200.0800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 14.984126 $749.2100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 25 25 33.033335 $1651.6800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 3.700000 $92.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 46.109526 $2305.4800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 25.771429 $1288.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 80 97 337.716664 $3377.1600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 13.142857 $938.9300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 1.571429 $112.2600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.800000 $57.1500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 3.857143 $275.5500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 7.714286 $551.1100 $71.4400
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Subtotal (Total Children Is Unduplicated) 186 286 657.797617 $24789.6800 $37.6900
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Total 296 667.614285 $24983.9300 $37.4200
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Number of Children (Unduplicated) With at Least One Authorization 193