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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 291 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 8 9 16.049207 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 9 16.049207 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 2.494444 $120.9800 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.5000 $23.5000
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Subtotal (Total Children Is Unduplicated) 4 4 3.494444 $144.4800 $41.3500
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.372222 $85.6100 $229.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 5.000000 $250.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 9 9 16.697619 $834.8800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 2.361111 $118.0600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 5 5 21.972221 $1098.6100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 14 15.861111 $793.0600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 23 24 37.726986 $1886.3600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 4.372222 $109.3100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 16 33.069047 $1653.4500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 18 19 45.742858 $2287.1400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.450000 $36.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 7.438888 $371.9400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 9 9 25.053174 $1252.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 2.005555 $50.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7 7 113.842857 $5692.1400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 5.747619 $287.3800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 107 127 532.762694 $5327.6300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 11.361904 $811.6900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 8.333333 $595.3300 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 2.571429 $183.7000 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 107.428571 $7674.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 4.066667 $290.5300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 4.138096 $295.6300 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 12.276190 $877.0100 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 31.695237 $2264.3100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.000000 $785.8400 $71.4400
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Subtotal (Total Children Is Unduplicated) 182 278 1064.347611 $35913.3300 $33.7400
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Total 291 1083.891262 $36057.8000 $33.2700
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Number of Children (Unduplicated) With at Least One Authorization 188