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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 676 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 2 2 1.677778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.677778 $0.0000 $0.0000
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 0.046575 $2.1000 $45.0200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.093151 $10.7200 $115.0600
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
SCREEN-T1023 SCREENING 2 2 2.000000 $100.0000 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 5.000000 $255.2500 $51.0500
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Subtotal (Total Children Is Unduplicated) 13 19 17.139726 $769.7200 $44.9100
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.966667 $98.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 6 6.500000 $325.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 185 217 486.511899 $24325.5700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 139 344.766670 $17238.3500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.400000 $20.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 73 74 160.333337 $8016.6900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 169 174 369.766667 $18488.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 16 71.152380 $3557.6200 $50.0000
INTR -T1013 INTERPRETER 4 4 20.200000 $1010.0100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 15.300000 $1093.0300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 15.714286 $898.8500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 5.571429 $318.6800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 2 2 9.714286 $693.9800 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 1 1 0.377778 $6.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 7 7 42.780952 $3056.2600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 11.857143 $164.5800 $13.8800
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Subtotal (Total Children Is Unduplicated) 254 655 1565.913494 $79793.0900 $50.9600
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Total 676 1584.730998 $80562.8000 $50.8400
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Number of Children (Unduplicated) With at Least One Authorization 257