Summary Report for FSPSAs Ending During the Report Period Center: 10
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 6139 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.866667 $32.2400 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 3 3 3.833333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 4.700000 $32.2400 $6.8600
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 4 4 14.571429 $230.8100 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 492 505 504.733334 $9847.3500 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 4.000000 $94.6800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 427 437 436.188889 $6403.2500 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 422 431 430.188889 $3789.9600 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 419 428 427.188889 $12354.3000 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 3.000000 $41.4300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 420 429 428.188889 $9009.0900 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 99 102 101.555556 $7629.8700 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 4.000000 $181.2800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 4.000000 $463.2400 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 10 12 16.322224 $816.1200 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 87 101 99.088889 $5094.1600 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 24 25 25.000000 $1285.2500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 121 139 135.338095 $6957.7300 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 1.142857 $58.7600 $51.4100
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Subtotal (Total Children Is Unduplicated) 739 2631 2636.507940 $64360.1100 $24.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 8 7.355556 $36778.0000 $5000.0300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 283 375 396.447621 $19822.4100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 41 48 58.077774 $2903.8700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 82 102 84.977775 $4248.8800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 179 217 225.326989 $11266.3700 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 7 7 45.775397 $2288.7700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.177778 $8.8900 $50.0100
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1001 1272 8304.834572 $415241.7300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 24.857143 $1242.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 342 412 2494.951599 $179536.6200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 327 404 1901.454756 $136828.5800 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 3.000000 $688.8300 $229.6100
SENS -V5264 EARMOLD 2 2 3.000000 $54.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 536 653 3713.118285 $267195.7800 $71.9600
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Subtotal (Total Children Is Unduplicated) 1511 3504 17263.355245 $1078105.9600 $62.4500
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Total 6139 19904.563185 $1142498.3100 $57.4000
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Number of Children (Unduplicated) With at Least One Authorization 1810