Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 01-01-16 and 03-31-16 Date of Report: 05-12-16 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2124 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 1 2 1.900000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 2 1.900000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.172223 $22.5100 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.172223 $12.2200 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.172223 $10.2600 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.172223 $25.6000 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.427778 $93.0100 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 1.644445 $37.6600 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.216667 $5.5300 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.216667 $10.1400 $46.8100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.216667 $25.9200 $119.6200
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 14 18 50.985712 $2549.2900 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 1 1 0.100000 $5.1100 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.072222 $3.6900 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.216667 $11.0600 $51.0600
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Subtotal (Total Children Is Unduplicated) 21 38 59.785717 $2811.9800 $47.0300
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.955556 $47.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 193 232 35.411735 $1770.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 71 80 4.401857 $110.0300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 161 327 417.274415 $20863.7500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 11 8.233694 $205.8500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 23 25 20.660893 $1033.0400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 23 25 25.082540 $1254.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 34 35 36.824604 $1841.2300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.714286 $42.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 621 666 3568.896775 $178445.0300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 135 149 718.798401 $51351.0400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 158 174 954.738086 $68206.5600 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.216667 $51.3800 $237.1600
SENS -V5264 EARMOLD 2 2 1.116667 $20.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 325 355 2268.321399 $162049.0800 $71.4400
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Subtotal (Total Children Is Unduplicated) 1000 2084 8062.647575 $487292.3800 $60.4400
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Total 2124 8124.333292 $490104.3600 $60.3300
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Number of Children (Unduplicated) With at Least One Authorization 1001