Summary Report for FSPSAs Ending During the Report Period Center: 57
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 2603 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 3 3 6.255556 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.066667 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 53.000000 $1961.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 10 10 59.322223 $1961.0000 $33.0600
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.238889 $13.5000 $56.4900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.477778 $21.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.477778 $54.9500 $115.0100
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.222222 $11.3400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 47 49 31.003174 $1582.7100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 0.805556 $41.1300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 42 43 22.448413 $1146.0000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 60 63 35.680801 $1821.5100 $51.0500
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Subtotal (Total Children Is Unduplicated) 104 165 91.354611 $4692.6300 $51.3700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.044444 $2.2200 $49.9500
CONOF -CONOF CONSULT, OT, FACE TO FACE 171 178 78.109520 $3905.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 15 16 5.394444 $269.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 370 382 167.917464 $8395.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.566667 $39.1700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 77 81 557.357140 $13933.9300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 716 749 4667.242802 $233362.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 718 762 4675.332486 $46753.3500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 77 82 316.788887 $22631.4300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.254762 $243.3700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 59 62 260.642856 $18620.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 12.571428 $718.5900 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.117808 $53.7200 $455.9700
SENS -V5264 EARMOLD 1 1 0.477778 $8.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 90 95 414.683331 $29625.0000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 26.499999 $367.8200 $13.8800
TRAV -TRAVS Travel by mile 5 5 80.428572 $35.7900 $0.4500
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Subtotal (Total Children Is Unduplicated) 817 2428 11269.430388 $378966.6600 $33.6300
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Total 2603 11420.107222 $385620.2800 $33.7700
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Number of Children (Unduplicated) With at Least One Authorization 836