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: 04-01-22 and 06-30-22 Date of Report: 08-08-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1185 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 22 24 23.225396 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 23 25 23.475396 $9.2500 $0.3900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 3 0.822222 $39.8800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 9.500000 $223.2500 $23.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 71 71 44.404764 $1043.5200 $23.5000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 2.571429 $135.1800 $52.5700
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Subtotal (Total Children Is Unduplicated) 86 86 57.298415 $1441.8300 $25.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 1.555555 $7777.5000 $4999.8200
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 6 4.783333 $239.1700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.500000 $37.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 1.622222 $81.1100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.083333 $54.1700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 34 39 35.963491 $1798.1700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 5 5 3.005555 $150.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.088889 $27.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 25 31.825399 $1591.2800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 3 3 14.021429 $701.0700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 22 23 20.943650 $1047.1800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 4 4 4.000000 $200.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.344444 $8.6100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 19 20 668.533331 $33426.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 250 264 1334.092039 $66704.6300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 48 51 298.219044 $14910.9500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 377 463 2015.572975 $20155.7400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 21 103.161903 $7369.9000 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 16 17 84.409522 $6030.2200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 23.285714 $1663.5300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 15 16 95.411110 $6816.1600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.088889 $6.3500 $71.4500
PHY -97110TL PT SESSION BY LICENSED PT 18 18 93.647617 $6690.1900 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 10.223810 $730.3900 $71.4400
SENS -V5264 EARMOLD 3 3 5.111111 $92.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 48 220.404756 $15745.7300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.000000 $71.4400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 20 20 110.833332 $7917.9500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 6 23.809525 $1700.9500 $71.4400
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Subtotal (Total Children Is Unduplicated) 469 1074 5214.541978 $204356.0300 $39.1900
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Total 1185 5295.315789 $205807.1100 $38.8700
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Number of Children (Unduplicated) With at Least One Authorization 493