Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2016 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 17 17 9.716666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 17 9.716666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 31 47 25.560505 $1239.6900 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.333333 $7.1800 $21.5500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $25.3100 $25.3100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.460274 $52.9300 $115.0100
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 6 5.266667 $268.8700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 44 49 28.739042 $1467.1300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 10 2.216667 $113.1600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.344444 $17.5800 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 50 58 32.493530 $1658.7900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 84 95 54.860123 $2800.6200 $51.0500
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Subtotal (Total Children Is Unduplicated) 180 269 151.274585 $7651.2700 $50.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 27 33 20.299392 $101497.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 304 341 752.731747 $37636.5800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 147 161 352.771425 $17638.5500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 141 157 302.794442 $15139.7000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 336 382 680.187305 $34009.3900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 342 375 2251.815897 $112590.6800 $50.0000
INTR -T1013 INTERPRETER 22 22 174.231746 $8711.5900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 50 55 383.452387 $27393.8100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 75 89 616.933341 $44073.7000 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.460274 $104.9500 $228.0100
SENS -V5264 EARMOLD 2 2 1.371385 $24.6900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 100 110 767.666677 $54842.0900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 12.000000 $686.4000 $57.2000
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Subtotal (Total Children Is Unduplicated) 557 1730 6317.716018 $454579.1100 $71.9500
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Total 2016 6478.707269 $462230.3800 $71.3500
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Number of Children (Unduplicated) With at Least One Authorization 586