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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2236 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 26 27 38.606348 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 26 27 38.606348 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.100000 $1.9500 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.100000 $26.0400 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.100000 $16.1500 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.100000 $7.9200 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.100000 $31.8100 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.100000 $23.1400 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.100000 $95.6300 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 6.000000 $300.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 10 29.657143 $1482.8500 $50.0000
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Subtotal (Total Children Is Unduplicated) 13 27 45.357143 $2191.9500 $48.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 191 280 367.531998 $18376.6000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 123 172 181.824605 $4545.6200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 68 72 67.425398 $3371.2800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 3 0.327702 $8.1900 $24.9900
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 56 49.761112 $2488.0600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 32 33 27.361111 $1368.0600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.450000 $11.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 70 71 68.900794 $3445.0400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 16.428571 $821.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 772 845 5488.885716 $274444.2100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 134 145 852.383334 $61337.4700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 136 146 939.457150 $67603.3200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 20.571429 $1480.3200 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 1.488889 $341.8700 $229.6100
SENS -V5264 EARMOLD 2 2 1.100000 $19.9400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 302 343 2277.557140 $163893.0300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 23.857142 $1716.7600 $71.9600
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Subtotal (Total Children Is Unduplicated) 1072 2182 10389.312091 $615372.4400 $59.2300
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Total 2236 10473.275582 $617564.3800 $58.9700
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Number of Children (Unduplicated) With at Least One Authorization 1091