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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 797 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
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $9.0800 $9.0800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.205479 $9.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.410959 $47.2700 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
SCREEN-T1023 SCREENING 5 5 5.000000 $250.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 6.000000 $306.3000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 14 18 18.616438 $853.7600 $45.8600
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.166667 $108.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 7.566667 $378.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 26 30.000000 $1500.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 228 268 721.204762 $36060.2400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 130 147 378.666669 $18933.3500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 1.933333 $96.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 74 175.533332 $8776.6600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 199 207 452.141662 $22607.0600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 16 18 84.566667 $4228.3400 $50.0000
INTR -T1013 INTERPRETER 7 7 78.104763 $3905.2400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 8 27.990475 $1999.6400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 3 14.323810 $819.3200 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 8.000000 $457.6000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 3 3 18.123810 $1294.7600 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 1 1 1.666667 $30.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 48.209524 $3444.0900 $71.4400
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Subtotal (Total Children Is Unduplicated) 298 779 2053.198808 $105120.6200 $51.2000
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Total 797 2071.815246 $105974.3800 $51.1500
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Number of Children (Unduplicated) With at Least One Authorization 301