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: 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 1035 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 44 45 21.922227 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 44 45 21.922227 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 18 14.261948 $691.7000 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.405479 $46.6300 $115.0100
OCTH -97167 OT EVAL HIGH COMPLEXITY 32 36 22.399651 $1143.5000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 39 40 19.924811 $1017.1700 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.277778 $14.1800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 45 50 25.205556 $1286.7500 $51.0500
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Subtotal (Total Children Is Unduplicated) 119 151 86.475223 $4404.1300 $50.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 16 11.895282 $59476.5000 $5000.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 10 13 9.711112 $485.5600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 4.188889 $209.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 110 157.876193 $7893.8300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 5 6 8.922221 $446.1100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 70 68.533335 $3426.6800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 148 164 180.273020 $9013.6800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 7 9 7.477777 $373.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 256 273 1328.341265 $66417.0700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 13 14 91.380951 $4569.0400 $50.0000
INTR -T1013 INTERPRETER 1 1 4.285714 $214.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 38 222.223810 $15875.6500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 43 48 207.233333 $14804.7300 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 2 3 11.142857 $796.0500 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.405479 $92.4500 $228.0100
SENS -V5264 EARMOLD 2 2 0.745205 $13.4100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 66 336.842858 $24064.0500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 5.666666 $78.6500 $13.8800
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Subtotal (Total Children Is Unduplicated) 419 839 2657.145967 $208251.0600 $78.3700
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Total 1035 2765.543417 $212655.1900 $76.8900
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Number of Children (Unduplicated) With at Least One Authorization 466