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: 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 2490 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 33 33 93.596829 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 33 33 93.596829 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 2.133333 $119.6800 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 1.766666 $34.4700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 1.766666 $41.8200 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 1.766666 $25.9300 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 1.766666 $15.5600 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 1.766666 $51.0900 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.433333 $5.9800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 1.333333 $28.0500 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 4 4 1.766666 $153.5900 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.433333 $19.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.433333 $50.1800 $115.8000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 11 12 57.495237 $2874.7700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 3.428571 $176.2600 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 17 18 127.623809 $6561.1500 $51.4100
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Subtotal (Total Children Is Unduplicated) 36 65 205.914278 $10260.9900 $49.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 3.455556 $17278.0000 $5000.0600
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.433333 $100.3600 $231.6000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 188 278 359.398903 $17969.9600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 134 185 179.591254 $4489.7800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 141 147 118.405551 $5920.2600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.233333 $5.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 81 84 71.461111 $3573.0600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 47 38.716665 $1935.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.477778 $11.9500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 98 79.794443 $3989.7200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.066666 $51.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 903 998 6580.338086 $329017.1900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 133 149 920.290472 $66224.1800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 108 132 726.472213 $52277.0100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 12.571429 $904.6400 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 1.333333 $153.0800 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.433333 $99.4900 $229.5900
SENS -V5264 EARMOLD 3 3 1.333333 $24.1700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 225 255 1707.033324 $122838.2000 $71.9600
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Subtotal (Total Children Is Unduplicated) 1130 2392 10803.840116 $626864.3500 $58.0200
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Total 2490 11103.351223 $637125.3400 $57.3800
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Number of Children (Unduplicated) With at Least One Authorization 1157