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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2266 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 29 29 42.000001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 42.000001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 2 0.327778 $7.7000 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 3 0.466667 $6.4700 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 3 0.466667 $4.2400 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 3 0.466667 $12.9900 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.011111 $0.9400 $84.7500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 3 0.466667 $7.7900 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 2 0.327778 $7.3400 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.011111 $90.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.011111 $231.2800 $115.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 3.428571 $171.4300 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 6 11.504763 $575.2400 $50.0000
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Subtotal (Total Children Is Unduplicated) 12 31 21.488891 $1115.9200 $51.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.011111 $5055.5000 $4999.9500
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.100000 $5.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 245 308 375.703677 $18785.1800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 115 117 88.538663 $2213.4700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 51 54 54.329365 $2716.4800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 50 53 73.292064 $3664.6100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 38 39 47.321427 $2366.0700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.000000 $75.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 51 51 45.520634 $2276.0300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 800 886 5047.254725 $252362.8700 $50.0000
INTR -T1013 INTERPRETER 2 2 10.428571 $521.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 121 133 697.323806 $49816.8400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 161 169 986.602372 $70482.8800 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 4 4 2.377778 $42.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 350 379 2332.038079 $166600.8500 $71.4400
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Subtotal (Total Children Is Unduplicated) 1196 2206 9769.842272 $577515.9900 $59.1100
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Total 2266 9833.331164 $578631.9200 $58.8400
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Number of Children (Unduplicated) With at Least One Authorization 1219