Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1901 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 11 12 26.131745 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 12 26.131745 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.361111 $6.4700 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.950000 $62.9800 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 0.838889 $10.5800 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 2.950000 $24.3700 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 2.950000 $74.6600 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.416667 $32.1400 $77.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 2.950000 $54.7200 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.588889 $53.5400 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.477778 $21.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.055556 $6.3900 $115.0900
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.300000 $15.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 23 24 89.604761 $4480.2400 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 28 50 108.443651 $4944.6900 $45.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.783333 $39.1700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 180 220 164.455925 $8222.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 69 73 33.406385 $835.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 85 90 154.080949 $7704.0300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 48 112.078583 $5603.9000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 61 99.503100 $4975.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 81 86 150.756349 $7537.8100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 17.338095 $433.4500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 3 9.000000 $225.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 602 649 3720.804759 $186040.3100 $50.0000
INTR -T1013 INTERPRETER 2 2 11.428571 $571.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 102 113 612.052391 $43725.0200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.285714 $302.3400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 130 147 772.270564 $55171.0300 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.178082 $11.5800 $65.0100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.055556 $12.6800 $228.1800
SENS -V5264 EARMOLD 2 2 0.416667 $7.5000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 288 330 1995.790473 $142579.2700 $71.4400
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Subtotal (Total Children Is Unduplicated) 907 1839 7862.685496 $469047.6300 $59.6500
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Total 1901 7997.260892 $473992.3300 $59.2700
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Number of Children (Unduplicated) With at Least One Authorization 915