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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2222 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 24 24 43.619046 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 24 24 43.619046 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.411111 $8.0200 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.316667 $31.1700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.316667 $19.3300 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.316667 $9.4800 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.316667 $38.0800 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 1.316667 $27.7000 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 3 3 1.316667 $114.4700 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.905556 $41.0400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.450000 $52.1100 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 3.714286 $185.7200 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 10 46.633333 $2331.6700 $50.0000
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 15 34 61.014288 $2910.2000 $47.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.322222 $11611.0000 $4999.9500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 185 270 374.224062 $18711.2000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 120 165 190.465082 $4761.6400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 73 79 74.604762 $3730.2500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 4 0.449925 $11.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 64 63.623809 $3181.1900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 28 21.188889 $1059.4500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 77 82 67.177778 $3358.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.544445 $38.6100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 28.338096 $1416.9100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 776 860 5793.576214 $289678.6200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 139 144 1061.059534 $76353.7800 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 9.714286 $699.0400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 107 118 845.091671 $60812.7800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 5.714286 $411.2000 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.905556 $207.9300 $229.6200
SENS -V5264 EARMOLD 3 3 1.316667 $23.8700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 296 329 2297.195258 $165306.0400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 11.428572 $822.3900 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1055 2164 10849.941114 $642196.0200 $59.1900
-------------------------------------------------------------------------------------------------------------------------------------
Total 2222 10954.574448 $645106.2200 $58.8900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1075