Summary Report for FSPSAs Initiated During the Report Period Center: 10
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 4774 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 2 2 0.500000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.500000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 417 423 423.000000 $8252.7300 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.000000 $71.0100 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 339 342 342.000000 $5020.5600 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 340 343 343.000000 $3021.8300 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 337 340 340.000000 $9832.8000 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 339 342 342.000000 $7195.6800 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 8 9 24.395239 $1219.7700 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 77 90 99.957142 $5138.7900 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 15 17 27.000000 $1388.0700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 102 124 148.617461 $7640.4300 $51.4100
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Subtotal (Total Children Is Unduplicated) 572 2037 2096.969842 $49045.6200 $23.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 6.000000 $30000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 262 304 328.450801 $16422.6000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 40 46 35.888890 $1794.4500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 61 64 70.700003 $3535.0200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 180 198 199.888893 $9994.4700 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.571429 $328.5700 $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 785 959 6883.849631 $344192.4300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 0.588889 $29.4500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 285 325 2175.748420 $156566.8300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 11.142857 $801.8400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 284 329 1853.276182 $133361.7700 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.8100 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 3 3 3.000000 $54.3900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 415 494 3159.896825 $227386.1900 $71.9600
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Subtotal (Total Children Is Unduplicated) 1289 2735 14738.180598 $924871.3000 $62.7500
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Total 4774 16835.650440 $973916.9100 $57.8500
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Number of Children (Unduplicated) With at Least One Authorization 1364