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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1393 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 73 74 37.201057 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 73 74 37.201057 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 36 28.118568 $1363.7500 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 9 9.533334 $265.3100 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 1.353424 $155.6500 $115.0100
OCTH -97167 OT EVAL HIGH COMPLEXITY 35 37 16.553325 $845.0400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 53 56 30.709078 $1567.6900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 67 69 36.268191 $1851.5000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.655556 $29.2100 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 158 216 125.191476 $6180.2500 $49.3700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 24 16.551902 $82759.5000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 113 115 99.000005 $4950.0300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.366667 $118.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 117 127 152.061111 $7603.0600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 1.311111 $65.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 84 102.236513 $5111.8500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 203 211 176.626197 $8831.3500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 0.800000 $40.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 316 334 1649.553170 $82477.6700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 49.695238 $2484.7700 $50.0000
INTR -T1013 INTERPRETER 1 1 8.714286 $435.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 41 217.266663 $15521.5700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 61 67 360.642857 $25764.3500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 2 4.000000 $285.7600 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 6 6 1.545205 $352.3300 $228.0100
SENS -V5264 EARMOLD 6 6 1.545205 $27.8200 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 70 74 409.469839 $29252.5300 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 505 1103 3254.385969 $266312.1600 $81.8300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1393 3416.778502 $272492.4200 $79.7500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 578