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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1434 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 65 66 30.788885 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 65 66 30.788885 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 24 20.097347 $974.7200 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $55.6600 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 0.580823 $66.7900 $115.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 38 43 15.023811 $766.9700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 52 59 26.021536 $1328.3900 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.238889 $12.2000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 2.011111 $102.6700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 60 64 30.688889 $1566.6700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.255556 $13.0500 $51.0600
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.677777 $30.1900 $44.5400
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Subtotal (Total Children Is Unduplicated) 155 203 97.595739 $4917.3000 $50.3800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 24 37.265231 $186326.5000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 14 17 23.033333 $1151.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 110 124 148.561113 $7428.0700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 1.500000 $75.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 63 67 66.299998 $3314.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 189 203 204.219048 $10210.9600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 6 7 5.233332 $261.6600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 415 467 1878.996825 $93949.7800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 22.352381 $1117.6200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 62 214.790477 $15344.6500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 68 74 328.623812 $23476.9200 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 6.142857 $438.8500 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 0.580823 $132.4200 $227.9900
SENS -V5264 EARMOLD 4 4 0.745206 $13.4100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 85 99 359.490479 $25681.9700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 6.033333 $83.7400 $13.8800
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Subtotal (Total Children Is Unduplicated) 646 1165 3304.868248 $369238.2100 $111.7300
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Total 1434 3433.252872 $374155.5100 $108.9800
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Number of Children (Unduplicated) With at Least One Authorization 707