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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2345 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 30 30 49.571427 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 30 30 49.571427 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 0.122222 $2.3800 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 0.183333 $4.3400 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 0.183333 $2.6900 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 0.183333 $1.6100 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 0.183333 $5.3000 $28.9100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 0.183333 $3.8600 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 4 4 0.244444 $21.2500 $86.9200
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.133333 $6.0400 $45.3100
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.138889 $16.0900 $115.8200
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 16.157143 $807.8600 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 14 14 53.966668 $2698.3300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 8 9 120.571429 $6198.5800 $51.4100
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Subtotal (Total Children Is Unduplicated) 32 54 194.250793 $9871.1400 $50.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.038889 $5194.5000 $5000.0500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 183 266 377.079856 $18854.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 134 185 178.635699 $4465.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 89 93 72.270632 $3613.5200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 3 0.588889 $14.7200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 64 50.017458 $2500.8700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 28 28 20.205554 $1010.2700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 77 80 62.194444 $3109.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 6 2.227778 $55.7000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 812 918 5546.619053 $277330.7300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 128 148 825.962696 $59436.2800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 116 139 861.807935 $62015.6800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 24.428572 $1757.8800 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.072222 $8.2900 $114.7800
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.133333 $30.6100 $229.5500
SENS -V5264 EARMOLD 3 3 0.183333 $3.3200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 282 320 1978.384135 $142364.4100 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.142857 $82.2400 $71.9600
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Subtotal (Total Children Is Unduplicated) 1074 2261 10002.993335 $581848.6200 $58.1700
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Total 2345 10246.815555 $591719.7500 $57.7500
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Number of Children (Unduplicated) With at Least One Authorization 1101