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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 600 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 46 46 29.631745 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 46 46 29.631745 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 9 9 7.516667 $364.5600 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.9200 $28.9200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.109589 $12.6900 $115.8200
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 1.000000 $55.5000 $55.5000
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 1.444445 $74.2600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 1.216667 $62.5500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 6 1.433333 $73.6900 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 16 10.611111 $545.5200 $51.4100
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Subtotal (Total Children Is Unduplicated) 30 41 24.331812 $1217.6900 $50.0500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 5 4.388889 $21944.5000 $5000.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 18 19 22.288890 $1114.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 106 128 137.822225 $6891.1300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 46 46.877777 $2343.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 111 131.066668 $6553.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 123 167 699.100001 $34955.0100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 6 26.076189 $1876.4400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 8 10 32.390476 $2330.8200 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.219178 $50.3300 $229.6300
SENS -V5264 EARMOLD 1 1 0.328767 $5.9600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 19 64.511110 $4642.2200 $71.9600
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Subtotal (Total Children Is Unduplicated) 319 513 1165.070170 $82708.0800 $70.9900
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Total 600 1219.033727 $83925.7700 $68.8500
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Number of Children (Unduplicated) With at Least One Authorization 368