Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2614 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 29 29 14.722224 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 14.722224 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 1.711111 $82.9900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $112.9800 $56.4900
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.505556 $25.8100 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.138889 $7.0900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 124 132 32.431745 $1655.6400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.261111 $13.3300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.055556 $2.8400 $51.0900
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.116667 $5.9600 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 105 109 39.734920 $2028.4700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 0.483333 $24.6700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 61 66 20.398414 $1041.3400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.094444 $4.8200 $51.0300
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 11 11 3.283333 $160.6800 $48.9400
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Subtotal (Total Children Is Unduplicated) 241 335 101.215079 $5166.6300 $51.0500
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 23 86 29.738890 $1486.9600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.588889 $29.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.433333 $21.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.533333 $26.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.488889 $24.4500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 120 140 874.999984 $21875.0200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 712 775 5309.428521 $265471.5900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 705 810 5497.158679 $54971.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 64 68 413.428563 $29535.3500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 89 98 480.571426 $27488.7100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 46 49 265.571423 $18972.4500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 91 99 534.178569 $30533.6800 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 0.477778 $8.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 25 123.928570 $8853.4700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 79 91 411.147618 $5706.7300 $13.8800
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Subtotal (Total Children Is Unduplicated) 912 2250 13944.674465 $465692.3900 $33.4000
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Total 2614 14060.611768 $470859.0200 $33.4900
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Number of Children (Unduplicated) With at Least One Authorization 944