Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2549 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 21 21 31.900000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 31.900000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 1.572223 $33.7400 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 1.572223 $40.9400 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.572223 $25.3900 $16.1500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 1.572223 $12.4500 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 1.572223 $50.0100 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 1.572223 $36.3800 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 3 3 1.572223 $123.0300 $78.2500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.466667 $66.4700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.466667 $169.8600 $115.8100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 5 39.676190 $1983.8100 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 14 15 50.376189 $2518.8200 $50.0000
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 24 27 154.142855 $8957.2500 $58.1100
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Subtotal (Total Children Is Unduplicated) 46 73 259.134129 $14076.2700 $54.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 223 352 476.380823 $23819.0600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 91 112 106.877631 $2671.9500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 151 165 137.249997 $6862.4900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 1.350000 $33.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 76 81 72.583333 $3629.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 51 53 42.222221 $2111.1100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.350000 $8.7500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 90 93 87.233332 $4361.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.428571 $21.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 908 1085 6993.747584 $377662.5600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 114 124 780.570630 $63476.0300 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.833333 $67.7600 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 10 12 63.142858 $4111.8700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 141 155 958.040467 $77907.8800 $81.3200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.105556 $12.1200 $114.8600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 1.466667 $336.7700 $229.6200
SENS -V5264 EARMOLD 3 3 1.572223 $28.5100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 186 207 1391.947612 $113193.2000 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 22.571429 $1469.8500 $65.1200
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Subtotal (Total Children Is Unduplicated) 1113 2455 11142.674267 $691835.8900 $62.0900
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Total 2549 11433.708396 $705912.1700 $61.7400
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Number of Children (Unduplicated) With at Least One Authorization 1137