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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1366 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 39 39 28.641271 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 39 39 28.641271 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 26 32 25.303883 $1227.2400 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 6 10.971429 $305.3300 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 5 1.145205 $131.6900 $114.9900
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.122222 $6.2400 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 34 36 18.891116 $964.3800 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.322222 $67.5000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 61 75 33.082465 $1688.8700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 63 70 38.894442 $1985.5500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.616667 $27.4700 $44.5500
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Subtotal (Total Children Is Unduplicated) 159 229 130.349651 $6404.2800 $49.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 23 17.053730 $85269.0000 $5000.0200
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 31 34 43.863490 $2193.1700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.633333 $40.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 112 130 179.088888 $8954.4400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 88 110.673811 $5533.7000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 198 228 261.713483 $13085.6300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 340 375 2028.940473 $101447.0800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 11.409524 $570.4800 $50.0000
INTR -T1013 INTERPRETER 2 2 7.266667 $363.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 40 227.819047 $16275.3800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 60 82 378.660317 $27051.4900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.533333 $109.5400 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 4 5 1.145205 $261.0800 $227.9800
SENS -V5264 EARMOLD 4 5 1.145205 $20.6100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 71 79 550.650790 $39338.5100 $71.4400
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Subtotal (Total Children Is Unduplicated) 528 1098 3823.597296 $300744.2700 $78.6500
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Total 1366 3982.588218 $307148.5500 $77.1200
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Number of Children (Unduplicated) With at Least One Authorization 568