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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2409 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 44 46 80.955556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 44 46 80.955556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.172222 $23.1000 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 1.400000 $32.8900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 1.400000 $19.4200 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 1.400000 $12.7100 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 1.400000 $38.9600 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 4 4 1.400000 $118.7800 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 1.400000 $23.3800 $16.7000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 5.142857 $257.1500 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 8 8 24.923810 $1246.2000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $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 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 17 41 45.638889 $2136.7800 $46.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 221 290 364.550143 $18227.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 159 189 162.484013 $4062.1000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 51 54 54.331745 $2716.5900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 27 29.905557 $1495.2900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 43 43 41.212698 $2060.6400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 53 56 62.496032 $3124.8000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.000000 $50.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 829 936 5667.447614 $283372.3600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.714286 $35.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 129 145 843.658727 $60271.0000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 141 151 923.323806 $65962.2700 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 3 3 1.288889 $23.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 380 420 2756.542393 $196927.4000 $71.4400
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Subtotal (Total Children Is Unduplicated) 1185 2322 10914.955903 $653581.8500 $59.8800
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Total 2409 11041.550348 $655718.6300 $59.3900
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Number of Children (Unduplicated) With at Least One Authorization 1221