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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2525 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 27 27 32.563493 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 27 27 32.563493 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 0.144445 $2.8200 $19.5200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.144445 $27.0900 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.144445 $16.8000 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.144445 $8.2400 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.144445 $33.1000 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 1.144445 $24.0800 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.138889 $8.4700 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.005556 $0.4900 $87.6300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.005556 $45.5700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.005556 $0.6500 $116.7200
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 16.176190 $808.8100 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 13 13 51.690475 $2584.5300 $50.0000
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Subtotal (Total Children Is Unduplicated) 20 39 74.888892 $3560.6500 $47.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.261111 $11305.5000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 195 280 358.934741 $17946.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 177 245 255.911020 $6397.7700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 87 92 74.238890 $3711.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 58 59 50.355555 $2517.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.438889 $10.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 41 32.927777 $1646.3900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 77 63.750000 $3187.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 1.922223 $48.0600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.142857 $307.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 867 966 5948.619006 $297431.2400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 142 167 870.730150 $62657.7700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 11.857143 $853.2400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 151 167 974.682134 $70138.1800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 7.714286 $555.1200 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.005556 $0.6400 $115.7100
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 1.005556 $230.9000 $229.6200
SENS -V5264 EARMOLD 3 3 1.144445 $20.7500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 310 346 2132.571412 $153460.0100 $71.9600
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Subtotal (Total Children Is Unduplicated) 1162 2459 10795.212751 $632427.6500 $58.5800
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Total 2525 10902.665136 $635988.3000 $58.3300
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Number of Children (Unduplicated) With at Least One Authorization 1184