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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1628 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 35 35 28.638096 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 35 28.638096 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 23 16.461111 $798.3600 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.000000 $86.1600 $28.7200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.342466 $39.3800 $114.9800
OCTH -97167 OT EVAL HIGH COMPLEXITY 35 42 20.264385 $1034.5000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 62 75 37.299166 $1904.1300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 111 124 93.423518 $4769.2800 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 6 4.636453 $206.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 199 276 175.427099 $8838.3700 $50.3800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 23 18.473289 $92367.0000 $5000.0300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 32 33 37.900002 $1895.0100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 102 116 144.110317 $7205.5100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.355556 $17.7800 $50.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 64 73 75.888891 $3794.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 158 189 217.095235 $10854.7500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 399 565 2457.234919 $122861.8200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 11.857143 $592.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 50 237.947619 $16998.9900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.566667 $89.6200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 66 96 464.947620 $33215.8500 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.219178 $49.9500 $227.9200
SENS -V5264 EARMOLD 2 2 0.515069 $9.2700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 123 165 607.279365 $43384.1100 $71.4400
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Subtotal (Total Children Is Unduplicated) 639 1317 4275.390870 $333336.9700 $77.9700
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Total 1628 4479.456065 $342175.3400 $76.3900
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Number of Children (Unduplicated) With at Least One Authorization 669