Summary Report for FSPSAs Ending During the Report Period Center: 10
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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2819 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 4 4 2.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 2.000000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 438 441 456.214286 $10716.4700 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 9.588889 $489.5100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 12 11.277778 $575.7300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 7.477778 $381.7400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 14 14 13.466667 $659.0600 $48.9400
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Subtotal (Total Children Is Unduplicated) 474 488 501.025398 $12938.4900 $25.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.388889 $1944.5000 $5000.1400
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 5.000000 $1150.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 264 272 208.086498 $10404.2800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 29 18.516668 $925.8400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 96 96 52.652373 $2632.5800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 146 148 111.684125 $5584.1900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 871 948 7018.649978 $350932.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 133 136 618.821430 $44208.5900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 91 96 380.244452 $21749.9900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 299 309 1220.509536 $87193.2800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 16.214286 $926.8100 $57.1600
SENS -V5264 EARMOLD 18 18 17.566667 $316.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 250 260 1263.250002 $90246.5900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.857143 $277.8300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 24.000000 $333.1200 $13.8800
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Subtotal (Total Children Is Unduplicated) 1238 2327 10960.442047 $618826.3600 $56.4600
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Total 2819 11463.467445 $631764.8500 $55.1100
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Number of Children (Unduplicated) With at Least One Authorization 1285