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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1672 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 13 14 5.633334 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 13 14 5.633334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 40 40 35.488890 $681.3900 $19.2000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $46.8000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $119.6000 $119.6000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 15 16 15.288889 $780.5000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 5 7 5.677778 $289.8500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 20 21 19.844444 $1013.0600 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 73 86 78.300001 $2931.2000 $37.4400
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 480 516 248.434119 $12421.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 68 71 49.249999 $2462.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 99 103 62.955550 $3147.7500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 331 344 199.203176 $9960.1700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 228 283 1740.373808 $87018.6800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 56 57 306.928571 $21926.9700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 65 68 377.428569 $26963.5400 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $237.1200 $237.1200
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 116 127 666.980952 $47649.1700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 2.000000 $27.7600 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 740 1572 3655.554744 $211833.3200 $57.9500
-------------------------------------------------------------------------------------------------------------------------------------
Total 1672 3739.488079 $214764.5200 $57.4300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 768