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: 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 1947 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 18 19 43.519352 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 19 43.519352 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 3 0.494444 $10.5600 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 3 0.494444 $6.2300 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 3 0.494444 $4.0800 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 3 0.494444 $12.5100 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 3 0.494444 $38.1300 $77.1200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 3 0.494444 $9.1700 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.150000 $3.1000 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 4 0.544444 $24.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 4 0.544444 $62.6100 $114.9900
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 13 15 37.833331 $1891.6800 $50.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 4.000000 $204.2000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.172222 $59.8400 $51.0500
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Subtotal (Total Children Is Unduplicated) 20 46 47.211105 $2326.6100 $49.2800
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.428571 $121.4300 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 204 260 208.235337 $10411.8200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 83 84 49.616585 $1240.4200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 52 53 39.134129 $1956.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 23.683333 $1184.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.900000 $72.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 39 21.376308 $1068.8000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 58 49.392857 $2469.6500 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 20.285715 $507.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 712 767 4993.477833 $249673.6800 $50.0000
INTR -T1013 INTERPRETER 7 7 22.736507 $1136.8300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 102 109 752.904766 $53787.4600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 123 132 824.839686 $58926.4800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 1.600000 $91.4600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 3 4 0.544444 $124.1200 $227.9800
SENS -V5264 EARMOLD 4 5 2.973015 $53.5100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 297 330 2312.476217 $165203.1900 $71.4400
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Subtotal (Total Children Is Unduplicated) 1025 1882 9328.605303 $548029.3600 $58.7500
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Total 1947 9419.335760 $550355.9800 $58.4300
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Number of Children (Unduplicated) With at Least One Authorization 1036