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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1332 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 5 5 2.911110 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 2.911110 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 2.800000 $38.8400 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 4.633333 $42.0700 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 2.800000 $77.9200 $27.8300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.800000 $62.7200 $22.4000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.035616 $4.0900 $114.9500
EXIT -EXIT EXIT ASSESSMENT 5 5 5.000000 $250.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 14 14 14.133333 $721.5100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 6 6.000000 $306.3000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 9 9 8.166667 $416.9100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
SCREEN-T1023 SCREENING 48 48 55.580952 $2779.0500 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 6.000000 $306.3000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $48.9400 $48.9400
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Subtotal (Total Children Is Unduplicated) 92 102 115.949901 $5411.9900 $46.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 4.550793 $22754.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.800000 $140.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 5.966667 $427.2800 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 11 33.678571 $1683.9300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 208 247 600.671432 $30033.5900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 142 172 394.150006 $19707.5300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 68 69 158.800000 $7940.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 140 145 338.866671 $16943.3600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 8.333333 $208.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 246 253 1399.402794 $69970.1600 $50.0000
INTR -T1013 INTERPRETER 2 2 4.071428 $203.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 77 83 393.757149 $28129.9900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 29 36 185.823816 $10629.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 43 44 193.469047 $13821.4000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 3 12.333333 $704.9700 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 3 3 6.111111 $110.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 134 139 733.297622 $52386.7600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 42.245239 $586.3700 $13.8800
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Subtotal (Total Children Is Unduplicated) 466 1225 4521.462345 $276661.6900 $61.1900
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Total 1332 4640.323356 $282073.6800 $60.7900
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Number of Children (Unduplicated) With at Least One Authorization 499