Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1094 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 15 17 16.146031 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 17 16.146031 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 6.000000 $338.9400 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.7100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 3.000000 $70.4700 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $27.7400 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $47.4000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $18.1600 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $9.9600 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $55.6600 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 2.000000 $169.6800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 4.000000 $66.8000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 11.571429 $259.2000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 7.000000 $315.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.283333 $32.5800 $114.9900
EXIT -EXIT EXIT ASSESSMENT 112 112 175.936967 $8796.8300 $50.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 10 10 4.328766 $240.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 0.076712 $5.7500 $74.9900
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 2.594444 $132.4400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.238889 $63.2500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.1000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $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) 138 163 235.030540 $11008.1100 $46.8400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 128 174 134.611316 $6730.5900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 30 38 21.533338 $538.3500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 219 250 650.170230 $32508.4900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 4.366667 $109.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 96 103 202.180949 $10109.0500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 45 94.161903 $4708.0900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.437500 $35.9400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 129 291.094047 $14554.7100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 3.571429 $89.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 119 129 921.300000 $46065.0400 $50.0000
INTR -T1013 INTERPRETER 4 5 7.428571 $371.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 95.285713 $6807.2200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.285714 $20.4100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 1 1 12.285714 $877.6900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.428571 $316.3800 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 15 16 99.204761 $7087.1800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.571429 $40.8200 $71.4400
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Subtotal (Total Children Is Unduplicated) 375 914 2545.917852 $131044.8100 $51.4700
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Total 1094 2797.094423 $142052.9200 $50.7900
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Number of Children (Unduplicated) With at Least One Authorization 457