Summary Report for FSPSAs Initiated During the Report Period Center: 57
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 1639 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
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.133333 $4.9300 $36.9900
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Subtotal (Total Children Is Unduplicated) 1 1 0.133333 $4.9300 $36.9900
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.272222 $15.3800 $56.4900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.544444 $24.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.544444 $62.6100 $114.9900
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.411111 $20.9900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 6.455553 $329.5400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.411111 $20.9900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 15 7.333332 $374.3600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 28 29 15.627776 $797.7900 $51.0500
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Subtotal (Total Children Is Unduplicated) 42 68 31.599993 $1646.1500 $52.0900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 6 2.150001 $107.5100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 219 225 114.874591 $5743.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 31 31 24.088095 $1204.4000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 423 426 206.745224 $10337.2000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.622222 $15.5600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 75 539.357140 $26967.8700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 750 775 5349.752361 $53497.5200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 25.428572 $1816.6200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 9 74.785715 $5342.6900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 12.142857 $694.0900 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.134247 $61.2000 $455.8400
SENS -V5264 EARMOLD 1 1 0.544444 $9.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 15 106.785714 $7628.7800 $71.4400
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Subtotal (Total Children Is Unduplicated) 764 1570 6457.411183 $113426.8900 $17.5700
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Total 1639 6489.144509 $115077.9700 $17.7300
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Number of Children (Unduplicated) With at Least One Authorization 777