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: 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 623 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 34 34 67.830158 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 34 34 67.830158 $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) 1 1 0.083333 $1.1600 $13.8600
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.083333 $0.7600 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.083333 $2.3200 $27.8200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.083333 $7.0700 $84.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.083333 $1.3900 $16.6900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.083333 $3.7500 $44.9800
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.083333 $9.5800 $114.9500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 2 10 2.749997 $131.7100 $47.9000
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 93 136 188.175739 $9408.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 58 68 59.334193 $1483.3600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 25 25 28.900000 $1445.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 16.766668 $838.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 11 12.666667 $633.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 34 38.766667 $1938.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 150 162 1007.091276 $50354.5300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 14.571428 $728.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 23 164.857144 $11777.4100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 1.914286 $136.7600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 15 16 98.895238 $7065.0700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.200000 $14.2900 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.083333 $18.9900 $227.9100
SENS -V5264 EARMOLD 1 1 0.083333 $1.5000 $17.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 71 77 518.597166 $37048.6100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.857143 $61.2300 $71.4400
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Subtotal (Total Children Is Unduplicated) 348 579 2152.760281 $122979.1200 $57.1300
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Total 623 2223.340436 $123110.8300 $55.3700
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Number of Children (Unduplicated) With at Least One Authorization 378