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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1174 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 53 53 28.266666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 53 53 28.266666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 15 13.666666 $662.8300 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 4.479452 $518.7700 $115.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 24 25 11.072223 $569.2300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 14 14 8.138889 $418.4200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 52 60 27.533335 $1415.5000 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 96 107 68.509743 $3522.0900 $51.4100
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Subtotal (Total Children Is Unduplicated) 171 223 133.400308 $7106.8400 $53.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 17 13.422221 $67110.5000 $4999.9500
CONIF -CONIF CONSULT, ITDS FACE TO FACE 8 9 12.300001 $615.0100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 66 86 127.211109 $6360.5500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 48 59.022221 $2951.1100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 74 83 111.352380 $5567.6200 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 -26.285714 $-1314.2900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 289 406 1748.195249 $87409.7500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 3 13.714286 $685.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 40 160.695236 $11563.6300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 69 87 341.158735 $24549.7900 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 3.431963 $788.0000 $229.6100
SENS -V5264 EARMOLD 2 2 1.715982 $31.1100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 95 114 545.976196 $39288.4000 $71.9600
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Subtotal (Total Children Is Unduplicated) 495 898 3111.909865 $245606.8900 $78.9200
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Total 1174 3273.576839 $252713.7300 $77.2000
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Number of Children (Unduplicated) With at Least One Authorization 551