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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1030 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 79 80 49.621992 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 79 80 49.621992 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 29 21.001523 $1018.5800 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $55.6600 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.586301 $67.4100 $114.9800
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 2.455556 $125.3600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 13 14 8.861112 $452.3600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 10 5.233334 $267.1700 $51.0500
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Subtotal (Total Children Is Unduplicated) 50 65 40.137826 $1986.5400 $49.4900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 5.461111 $27305.5000 $4999.9900
CONIF -CONIF CONSULT, ITDS FACE TO FACE 194 216 335.731744 $16786.5900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 126 145 184.020631 $9201.0200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 81 90 124.481750 $6224.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 223 245 295.901591 $14795.1000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 124 135 844.063488 $42203.1900 $50.0000
INTR -T1013 INTERPRETER 2 2 12.285714 $614.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 44.828570 $3202.5500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 17 19 93.176190 $6656.5100 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 0.586301 $133.6500 $227.9600
SENS -V5264 EARMOLD 3 3 0.586301 $10.5500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 13 55.871428 $3991.4500 $71.4400
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Subtotal (Total Children Is Unduplicated) 388 885 1996.994819 $131124.4900 $65.6600
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Total 1030 2086.754637 $133111.0300 $63.7900
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Number of Children (Unduplicated) With at Least One Authorization 467