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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 596 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 22 33.296827 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 22 33.296827 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.083333 $1.6400 $19.7000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.083333 $1.9600 $23.4800
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.083333 $15.0300 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.083333 $9.8400 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.083333 $30.1500 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.083333 $7.0700 $84.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.455555 $7.6100 $16.7000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 4 20.000000 $1000.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 8.509524 $425.4800 $50.0000
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Subtotal (Total Children Is Unduplicated) 9 19 32.465077 $1498.7600 $46.1700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 86 113 147.577989 $7378.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 28 28 19.204111 $480.1000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 38 39 45.166666 $2258.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 33 46.933333 $2346.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 29 31.926190 $1596.3100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 3.000000 $75.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 39 39 55.337302 $2766.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 149 159 1026.309521 $51315.4900 $50.0000
INTR -T1013 INTERPRETER 1 1 1.000000 $50.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 19 138.285713 $9879.1400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 19 19 140.933332 $10068.2800 $71.4400
SENS -V5264 EARMOLD 2 2 0.827777 $14.9000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 60 65 515.661907 $36838.8900 $71.4400
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Subtotal (Total Children Is Unduplicated) 330 555 2178.163841 $140143.8700 $64.3400
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Total 596 2243.925745 $141642.6300 $63.1200
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Number of Children (Unduplicated) With at Least One Authorization 357