Summary Report for FSPSAs Ending During the Report Period Center: 52
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1489 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 1 1 1.000000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.211111 $44.8100 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.211111 $44.8100 $20.2700
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 4.074429 $51.3800 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 4.074429 $33.6500 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 4.033333 $102.0800 $25.3100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 4.074429 $84.2600 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 2.227397 $100.2300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.227397 $256.1500 $115.0000
EXIT -EXIT EXIT ASSESSMENT 7 7 7.000000 $350.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 11.156165 $569.5200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 5.063014 $258.4700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.688889 $35.1700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
SCREEN-T1023 SCREENING 45 47 41.801978 $2090.1000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 2.156165 $110.0700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 24 25 24.299999 $1240.5100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 6 6 6.000000 $306.3000 $51.0500
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Subtotal (Total Children Is Unduplicated) 105 141 127.877624 $6047.3400 $47.2900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.071233 $5356.0000 $4999.8500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 6.766667 $338.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 3.012500 $150.6300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 202 248 537.280158 $26864.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.266667 $56.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 146 175 370.506351 $18525.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.750000 $18.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 86 90 191.244441 $9562.2100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 189 203 404.216669 $20210.8500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.200000 $155.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 14.285714 $714.2900 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 4.579615 $228.9800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 225 244 1213.280753 $60664.0400 $50.0000
INTR -T1013 INTERPRETER 2 2 12.766667 $638.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 75 80 345.490474 $24681.8600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 23 23 130.728568 $7477.6800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 57 63 291.408330 $20818.2100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 18.846428 $1077.2600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 5.000000 $1140.0000 $228.0000
SENS -V5264 EARMOLD 5 5 2.900001 $52.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 161 180 956.979751 $68366.6700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.428571 $24.5200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 8.285714 $115.0100 $13.8800
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Subtotal (Total Children Is Unduplicated) 404 1345 4528.295272 $267236.8000 $59.0100
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Total 1489 4658.384007 $273328.9500 $58.6700
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Number of Children (Unduplicated) With at Least One Authorization 430