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 659 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 41 43 77.188889 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 41 43 77.188889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.172222 $3.3900 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.172222 $4.0500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.172222 $2.3900 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.172222 $1.5600 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.172222 $4.7900 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.172222 $14.6100 $84.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.172222 $2.8800 $16.7000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 6.142857 $307.1500 $50.0000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3 9 9.348411 $442.9100 $47.3800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.000000 $15000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 130 183.096135 $9154.8000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 57 67 57.507403 $1437.6900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 33 36 40.676189 $2033.8100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 20 22.872223 $1143.6200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 22 24.962699 $1248.1400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 37 40 54.069047 $2703.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 144 157 909.461905 $45473.0800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 20 100.714285 $7195.0400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 22 22 146.261902 $10448.9700 $71.4400
SENS -V5264 EARMOLD 1 1 0.172222 $3.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 83 87 577.513825 $41257.5900 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 344 607 2122.307835 $137149.2700 $64.6200
-------------------------------------------------------------------------------------------------------------------------------------
Total 659 2208.845135 $137592.1800 $62.2900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 383