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: 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 1382 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 1.555556 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.033333 $1.2300 $36.9600
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Subtotal (Total Children Is Unduplicated) 5 5 1.588889 $1.2300 $0.7800
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.357078 $32.6900 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.357078 $21.4000 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.357078 $65.6000 $27.8300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.357078 $52.8000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.276712 $12.4500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.276712 $31.8200 $115.0000
EXIT -EXIT EXIT ASSESSMENT 3 3 3.000000 $150.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 10.000000 $510.5000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 7.366667 $376.0700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 51 51 51.700000 $2585.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 18 18.000000 $918.9000 $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) 93 111 110.048403 $5265.6200 $47.8500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.468254 $17341.0000 $4999.9200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.366667 $118.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 3.366667 $168.3400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 5.600000 $401.0200 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 17 19 20.816667 $1040.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.366667 $34.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 220 273 541.066670 $27053.3500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 148 174 357.083334 $17854.1700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 80 86 178.733334 $8936.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 155 168 334.766665 $16738.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 4.733333 $118.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 214 221 977.123015 $48856.1700 $50.0000
INTR -T1013 INTERPRETER 4 4 23.142857 $1157.1400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 69 73 292.880948 $20923.4200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 23 26 104.899999 $6000.2800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 58 61 261.116663 $18654.1700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.033333 $1.9000 $57.1000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 4 4 6.722223 $121.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 121 142 607.995232 $43435.2100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 5.600000 $77.7300 $13.8800
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Subtotal (Total Children Is Unduplicated) 403 1266 3733.882528 $229259.5600 $61.4000
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Total 1382 3845.519820 $234526.4100 $60.9900
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Number of Children (Unduplicated) With at Least One Authorization 429