Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2211 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 70 71 50.046827 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 70 71 50.046827 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 36 43 33.512784 $1625.3700 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 4.000000 $111.3200 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 0.767122 $88.2200 $115.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 39 41 25.371690 $1295.2300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 66 73 37.714460 $1925.3200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 66 74 39.038357 $1992.9200 $51.0500
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Subtotal (Total Children Is Unduplicated) 176 241 141.404413 $7089.4200 $50.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 33 39 27.077244 $135386.0000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.252055 $57.9800 $230.0400
CONIF -CONIF CONSULT, ITDS FACE TO FACE 352 410 516.076182 $25803.7700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 169 182 213.933331 $10696.6600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 146 170 199.991271 $9999.5700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 352 384 450.872213 $22543.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 394 458 2141.450777 $107072.6000 $50.0000
INTR -T1013 INTERPRETER 4 4 27.069842 $1353.5000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 46 240.449210 $17177.6900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 88 103 588.993645 $42077.7700 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 6 7 1.115067 $254.2400 $228.0100
SENS -V5264 EARMOLD 5 6 1.019177 $18.3500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 78 89 511.671426 $36553.8000 $71.4400
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Subtotal (Total Children Is Unduplicated) 640 1899 4919.971440 $408995.4800 $83.1300
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Total 2211 5111.422680 $416084.9000 $81.4000
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Number of Children (Unduplicated) With at Least One Authorization 705