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 677 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 38 38 57.557147 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 38 38 57.557147 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.261111 $29.6400 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.577778 $37.0800 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.261111 $18.3900 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.261111 $12.3500 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.261111 $36.2200 $28.7200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.261111 $17.2900 $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
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Subtotal (Total Children Is Unduplicated) 3 16 9.405555 $277.5700 $29.5100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.261111 $1305.5000 $4999.7900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 86 139 226.005480 $11300.2700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 18 27 31.000000 $775.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 71 72 92.745237 $4637.2600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 58 56.794445 $2839.7300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 38 35.816667 $1790.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 64 64 65.622223 $3281.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 97 99 705.322228 $35266.1200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 23 166.414285 $11888.6400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 24 27 162.838095 $11633.1500 $71.4400
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 64 71 517.455554 $36967.0200 $71.4400
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Subtotal (Total Children Is Unduplicated) 333 623 2064.275325 $121777.6400 $58.9900
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Total 677 2131.238027 $122055.2100 $57.2700
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Number of Children (Unduplicated) With at Least One Authorization 368