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 1332 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
----------------------------------------------------------------------------
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 18 19 19.000000 $370.6900 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 11 11.000000 $161.4800 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 11 11.000000 $96.9100 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 11 11.000000 $318.1200 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 10 11 11.000000 $231.4400 $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 15 18 18.000000 $925.3800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 24 29 47.714286 $2452.9900 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 63 123 157.109525 $6040.7300 $38.4500
EI Services, Class # 03
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 273 316 2395.857156 $119792.8100 $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 66 74 588.826987 $42371.9900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 11.142857 $801.8400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 52 56 427.014283 $30727.9300 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 130 143 1018.503964 $73291.5600 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 626 1207 5085.611930 $299379.1700 $58.8700
-------------------------------------------------------------------------------------------------------------------------------------
Total 1332 5243.221455 $305419.9100 $58.2500
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 647