Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 536 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 6 6 5.311111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 6 6 5.311111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.600000 $23.4900 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.600000 $14.1000 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.600000 $46.2700 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.600000 $33.6600 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.131507 $5.9600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.131507 $15.2300 $115.8000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 2 2 2.000000 $100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 4 10 10.663014 $341.5300 $32.0300
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 4 6.833333 $341.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 166 193 523.757142 $26187.8500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 98 121 290.990474 $14549.5100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 66 75 189.066662 $9453.3100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 101 103 230.633336 $11531.6800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.200000 $30.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 15 80.828574 $4041.4200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 8.714286 $627.0800 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 10.000000 $719.6000 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 1 1 0.533333 $9.6700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 9.666667 $695.6200 $71.9600
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Subtotal (Total Children Is Unduplicated) 239 520 1353.223807 $68646.6200 $50.7300
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Total 536 1369.197932 $68988.1500 $50.3900
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Number of Children (Unduplicated) With at Least One Authorization 245