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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 670 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 30 31 69.353970 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 30 31 69.353970 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.383333 $9.0100 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.550000 $12.9300 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.383333 $5.5900 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.383333 $3.7500 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.383333 $11.0100 $28.7200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.383333 $32.5200 $84.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.383333 $5.2600 $13.7100
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Subtotal (Total Children Is Unduplicated) 2 8 2.849998 $80.0600 $28.0900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 93 152 230.500000 $11525.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 25 30 31.005556 $775.1400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 59 59 74.870635 $3743.5300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 48 48 45.294444 $2264.7200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 26 22.683335 $1134.1800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 57 57 56.011112 $2800.5600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 111 126 726.232540 $36311.6100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 27 163.280952 $11664.7900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 19 23 160.109527 $11438.2200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.285714 $91.8500 $71.4400
SENS -V5264 EARMOLD 1 1 0.383333 $6.9000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 69 78 517.067464 $36939.2500 $71.4400
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Subtotal (Total Children Is Unduplicated) 325 631 2031.724612 $118770.7400 $58.4600
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Total 670 2103.928580 $118850.8000 $56.4900
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Number of Children (Unduplicated) With at Least One Authorization 354