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 1521 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
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Subtotal (Total Children Is Unduplicated) 4 4 6.322223 $0.0000 $0.0000
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
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 7.121430 $363.5500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.483333 $24.6700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 14 3.533335 $180.3900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 22 9.893653 $505.0800 $51.0500
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Subtotal (Total Children Is Unduplicated) 36 54 22.226196 $1163.6300 $52.3500
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 1 1 10.428571 $260.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 77 83 432.050790 $21602.5400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 718 762 4675.332486 $46753.3500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 19.214286 $1372.6700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 11 33.214286 $2372.8200 $71.4400
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 12 14 74.714285 $5337.6000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 7.571429 $105.0900 $13.8800
TRAV -TRAVS Travel by mile 5 5 80.428572 $35.7900 $0.4500
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Subtotal (Total Children Is Unduplicated) 737 1463 5586.582830 $90515.3500 $16.2000
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Total 1521 5615.131249 $91678.9800 $16.3300
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Number of Children (Unduplicated) With at Least One Authorization 751