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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1323 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 4 4 3.188890 $118.6300 $37.2000
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Subtotal (Total Children Is Unduplicated) 4 4 3.188890 $118.6300 $37.2000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.966667 $89.1300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
OCTF -97168 OT RE-EVAL EST PLAN CARE 8 8 2.466667 $126.8100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 3.866668 $198.7900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 7 1.505557 $77.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 0.855556 $43.9900 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 20 24 7.605557 $391.0100 $51.4100
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Subtotal (Total Children Is Unduplicated) 37 57 19.266672 $1042.9500 $54.1300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 4 0.477778 $23.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 409 423 303.238090 $15161.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 43 59.185710 $2959.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 476 496 294.584122 $14729.2000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 239 262 1441.298412 $72064.9300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 31.714287 $2282.1600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 4 4 38.571429 $2775.6000 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 6 8 32.857144 $2364.3900 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 13.857144 $798.1700 $57.6000
TRAV -TRAVS Travel by mile 10 11 57.228570 $25.4700 $0.4400
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Subtotal (Total Children Is Unduplicated) 619 1262 2275.012686 $113432.7000 $49.8600
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Total 1323 2297.468248 $114594.2800 $49.8800
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Number of Children (Unduplicated) With at Least One Authorization 636