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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 930 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 3 3 1.022222 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.022222 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 134 134 157.279365 $3694.4900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 10.428571 $510.3800 $48.9400
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Subtotal (Total Children Is Unduplicated) 141 142 171.707936 $4371.8900 $25.4600
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 170 175 120.803178 $6040.1800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 11 5.911112 $295.5600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 48 33.311110 $1665.5500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 78 44.677778 $2233.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 261 272 1936.301576 $96815.1200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 26 27 120.309529 $8594.8900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 28 28 119.285716 $6823.1400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 68 69 313.784921 $22416.8000 $71.4400
SENS -V5264 EARMOLD 2 2 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 67 70 338.480158 $24181.0300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 44.857143 $622.6200 $13.8800
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Subtotal (Total Children Is Unduplicated) 530 785 3080.722221 $169954.7600 $55.1700
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Total 930 3253.452379 $174326.6500 $53.5800
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Number of Children (Unduplicated) With at Least One Authorization 617