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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1802 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 14 17 37.731747 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 17 37.731747 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.216667 $3.8800 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.372223 $7.9500 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.216667 $2.7300 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.372223 $3.0800 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.372223 $9.4200 $25.3200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.155556 $12.0000 $77.1500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.155556 $2.8900 $18.5600
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.233333 $10.5000 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.233333 $26.8300 $114.9800
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 13 16 36.242858 $1812.1400 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.050000 $2.5500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.233333 $11.9100 $51.0400
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Subtotal (Total Children Is Unduplicated) 19 32 40.853972 $2007.9800 $49.1500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 189 248 222.603592 $11130.2200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 64 64 46.455642 $1161.3800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 46 46 31.303890 $1565.2000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.550793 $13.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 25 13.598412 $679.9200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.083333 $2.0800 $24.9900
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 21 11.377776 $568.8800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 57 38.726187 $1936.3000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.966667 $74.1700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 11.714286 $292.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 642 706 4060.127756 $203006.4600 $50.0000
INTR -T1013 INTERPRETER 1 2 9.428572 $471.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 95 109 548.714282 $39200.1500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 123 144 786.538093 $56190.3300 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.233333 $53.1900 $227.9700
SENS -V5264 EARMOLD 2 2 0.372223 $6.7000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 278 320 1848.730152 $132073.3400 $71.4400
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Subtotal (Total Children Is Unduplicated) 939 1753 7633.524989 $448426.3600 $58.7400
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Total 1802 7712.110708 $450434.3400 $58.4100
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Number of Children (Unduplicated) With at Least One Authorization 951