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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2330 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 44 66.857148 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 44 44 66.857148 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 1.577778 $37.0800 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.577778 $37.0800 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.577778 $23.0000 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.577778 $15.4500 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.577778 $45.3100 $28.7200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 1.577778 $21.6300 $13.7100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.261111 $11.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.261111 $30.0300 $115.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 7 7 17.419047 $870.9500 $50.0000
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Subtotal (Total Children Is Unduplicated) 10 28 28.407937 $1177.1200 $41.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 1.400000 $7000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 164 256 369.077856 $18453.9000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 155 228 241.256843 $6031.4200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 97 103 111.337299 $5566.8600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 8 5.488889 $137.2200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 77 79 72.433334 $3621.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.450000 $11.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 48 45.227777 $2261.3900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.450000 $11.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 84 85 80.058731 $4002.9400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 4.038889 $100.9700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 699 772 5418.540480 $270927.1300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 133 146 979.109516 $69947.6800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 150 162 1114.280945 $79604.3100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 25.476190 $1820.0200 $71.4400
SENS -V5264 EARMOLD 2 2 1.316667 $23.7000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 319 356 2620.374585 $187199.7300 $71.4400
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Subtotal (Total Children Is Unduplicated) 1010 2258 11090.318001 $656721.4300 $59.2200
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Total 2330 11185.583086 $657898.5500 $58.8200
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Number of Children (Unduplicated) With at Least One Authorization 1044