Summary Report for FSPSAs Initiated During the Report Period Center: 10
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1183 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 0.300000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.300000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 276 279 287.857143 $6761.7600 $23.4900
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.122222 $57.2900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 5.000000 $244.7000 $48.9400
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Subtotal (Total Children Is Unduplicated) 288 292 299.979365 $7370.0500 $24.5700
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 195 195 153.961104 $7698.0200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 21 22 12.699999 $635.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 57 56.166668 $2808.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 108 108 57.877775 $2893.8800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 270 299 2393.017462 $119650.8700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 17.142857 $171.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 13 48.315079 $3451.6200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 31 33 190.428573 $10892.5000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 64 65 301.568254 $21544.0200 $71.4400
SENS -V5264 EARMOLD 3 3 3.000000 $54.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 75 78 374.505955 $26754.7100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 15 15 145.923810 $2025.4200 $13.8800
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Subtotal (Total Children Is Unduplicated) 541 890 3755.607536 $198809.8000 $52.9400
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Total 1183 4055.886901 $206179.8500 $50.8300
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Number of Children (Unduplicated) With at Least One Authorization 750