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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1956 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 17 17 29.568558 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 17 29.568558 $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 6 6 3.733333 $79.7100 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 1.594444 $20.1100 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 3.733333 $30.8400 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 3.733333 $94.4900 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 4 4 1.005555 $77.5500 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 1.005555 $18.6500 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.927778 $60.5500 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.405555 $18.2500 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 0.566666 $65.1600 $114.9900
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 21 26 43.869838 $2193.5000 $50.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.366667 $120.8200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 29 71 66.303168 $2837.1400 $42.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 0.322222 $1611.0000 $4999.6600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.522222 $26.1100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 223 285 239.795150 $11989.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 89 92 55.402278 $1385.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 44 46 33.965080 $1698.2600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 19 13.431746 $671.5900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 33 35 21.070611 $1053.5200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 37 38 27.000002 $1350.0100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 666 744 4237.369043 $211868.5000 $50.0000
INTR -T1013 INTERPRETER 7 8 34.593650 $1729.6800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 92 104 559.190477 $39948.5600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 139 152 791.305560 $56530.8600 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 0.405555 $92.4500 $227.9700
SENS -V5264 EARMOLD 4 5 0.988888 $17.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 293 333 1812.157140 $129460.5400 $71.4400
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Subtotal (Total Children Is Unduplicated) 1005 1868 7827.519624 $459433.7400 $58.6900
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Total 1956 7923.391350 $462270.8700 $58.3400
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Number of Children (Unduplicated) With at Least One Authorization 1019