Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1347 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
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Subtotal (Total Children Is Unduplicated) 1 1 1.000000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.274429 $28.6800 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.274429 $18.7900 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.233333 $56.5200 $25.3100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.274429 $47.0300 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.041096 $1.8500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.041096 $4.7300 $115.0100
EXIT -EXIT EXIT ASSESSMENT 9 9 8.131507 $406.5800 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 6.833791 $348.8700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 10 10 12.095238 $617.4700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.688889 $35.1700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 6.049315 $308.8200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 37 38 33.938660 $1696.9300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.000000 $459.4500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 3.134247 $160.0000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 19 20 20.000000 $1021.0000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 4 4 4.000000 $204.2000 $51.0500
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Subtotal (Total Children Is Unduplicated) 104 122 115.010459 $5518.1800 $47.9800
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.733333 $136.6700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.100000 $150.3800 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 7.279167 $363.9600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 210 231 525.018257 $26250.9300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 146 162 385.546829 $19277.3600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.083334 $52.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 75 78 189.571431 $9478.5800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 159 166 371.766671 $18588.3600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.333334 $33.3400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.892857 $44.6500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 227 240 1405.385537 $70269.2000 $50.0000
INTR -T1013 INTERPRETER 3 3 41.547619 $2077.3800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 71 78 358.200403 $25589.8100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 23 24 150.076193 $8584.3600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 46 47 206.942856 $14783.9900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 10.157143 $580.5800 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 2 2 2.266667 $40.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 163 169 951.302385 $67960.9900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.000000 $286.0000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 13.857143 $192.3400 $13.8800
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Subtotal (Total Children Is Unduplicated) 441 1224 4634.061159 $264969.7400 $57.1800
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Total 1347 4750.071618 $270487.9200 $56.9400
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Number of Children (Unduplicated) With at Least One Authorization 469