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: 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 1340 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 3.500000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 3.500000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 8.541096 $118.4700 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 5.741096 $52.1300 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 8.541096 $237.7000 $27.8300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 8.541096 $191.3200 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 1.738356 $78.2200 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 1.501370 $172.6500 $114.9900
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 7 7 7.000000 $350.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 9 9.000000 $459.4500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
SCREEN-T1023 SCREENING 42 42 41.961904 $2098.1000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 3.000000 $153.1500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 9.000000 $459.4500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 4.000000 $195.7600 $48.9400
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Subtotal (Total Children Is Unduplicated) 89 120 123.566014 $5331.0900 $43.1400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.400000 $7000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.033333 $1.6700 $49.9500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 8.000000 $400.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.966667 $140.8400 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 10 16.600000 $830.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.133333 $3.3300 $24.9900
CONIF -CONIF CONSULT, ITDS FACE TO FACE 183 231 541.300004 $27065.0200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 3.533333 $88.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 133 174 425.471433 $21273.5900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 69 77 201.666670 $10083.3500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 142 153 361.471427 $18073.5600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.066667 $1.6700 $25.0100
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 196 215 1006.372618 $50318.6900 $50.0000
INTR -T1013 INTERPRETER 8 8 82.023811 $4101.1900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 74 79 294.309919 $21025.5100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 29 34 218.826190 $12516.8500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 42 48 227.888095 $16280.3300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 22.885714 $1308.1500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 3.400000 $775.2000 $228.0000
SENS -V5264 EARMOLD 8 8 7.666667 $138.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 136 147 680.917852 $48644.7900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 9 41.790475 $580.0500 $13.8800
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Subtotal (Total Children Is Unduplicated) 389 1215 4148.724208 $240715.1100 $58.0200
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Total 1340 4275.790222 $246046.2000 $57.5400
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Number of Children (Unduplicated) With at Least One Authorization 414