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: 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 2025 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 54 55 46.476192 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 54 55 46.476192 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 38 42 29.671003 $1439.0400 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 5.142857 $143.1300 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.293151 $33.7100 $114.9800
OCTH -97167 OT EVAL HIGH COMPLEXITY 38 44 23.828463 $1216.4500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 66 74 47.880366 $2444.3000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 68 75 37.075039 $1892.6800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.305556 $15.6000 $51.0600
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Subtotal (Total Children Is Unduplicated) 173 241 144.196435 $7184.9000 $49.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 38 43 31.487671 $157439.0000 $5000.0200
CONIF -CONIF CONSULT, ITDS FACE TO FACE 311 377 532.360319 $26618.0300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 157 182 214.199999 $10710.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 117 135 186.249207 $9312.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 287 330 361.677769 $18083.8500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 357 429 2060.663511 $103033.1700 $50.0000
INTR -T1013 INTERPRETER 1 1 0.866667 $43.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 47 251.523814 $17968.8500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 78 95 429.009530 $30648.4600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 8.866667 $506.8200 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.293151 $66.8300 $227.9600
SENS -V5264 EARMOLD 2 2 0.293151 $5.2800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 74 84 423.495245 $30254.4700 $71.4400
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Subtotal (Total Children Is Unduplicated) 568 1729 4500.986701 $404690.5400 $89.9100
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Total 2025 4691.659328 $411875.4400 $87.7900
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Number of Children (Unduplicated) With at Least One Authorization 619