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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 470 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 22 23 48.746033 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 23 48.746033 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.194444 $3.8300 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.194444 $4.5700 $23.4800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.194444 $2.7000 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.194444 $1.7700 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.194444 $5.4100 $27.8200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.194444 $16.4900 $84.8200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.194444 $3.2500 $16.7000
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Subtotal (Total Children Is Unduplicated) 1 7 1.361108 $38.0100 $27.9300
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.188889 $9.4500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 3.142857 $225.0600 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 116 78.087635 $3904.3700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 28 29 21.312980 $532.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 20 21 23.231744 $1161.5800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 17.182649 $859.1400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.033333 $25.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 18 16.330213 $816.5100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 30 31 29.043759 $1452.1900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.250000 $31.2500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 103 105 577.166661 $28858.3600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 13 59.728572 $4267.0100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 25 27 168.128570 $12011.1100 $71.4400
SENS -V5264 EARMOLD 1 1 0.194444 $3.5000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 58 59 344.928570 $24641.7000 $71.4400
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Subtotal (Total Children Is Unduplicated) 283 440 1341.950876 $78824.8800 $58.7400
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Total 470 1392.058017 $78862.8900 $56.6500
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Number of Children (Unduplicated) With at Least One Authorization 304