Summary Report for FSPSAs Ending During the Report Period Center: 53
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 652 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 13 13 11.144446 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 11.144446 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 0.250000 $12.1300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.072222 $117.0600 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 2.383334 $33.0600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 25 26 9.111112 $215.9400 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $9.0800 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 2.000000 $100.0000 $50.0000
SCREEN-T1023 SCREENING 2 2 2.700000 $135.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 39 42 21.516668 $695.0900 $32.3000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 2.566666 $12833.0000 $4999.8700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 2.255555 $112.7800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 3.033333 $697.6600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4 7 7.250000 $362.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 12 14 9.571428 $478.5800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 3 3 1.622222 $81.1100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 4.285714 $107.1400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 10.896825 $544.8400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 21 21 21.238889 $1061.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.616666 $65.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 10.955556 $547.7800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 13 13 14.255556 $712.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 20 20 16.316668 $815.8400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 25 25 27.122223 $1356.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.300000 $7.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 16.000000 $400.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 2.050000 $102.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 97 102 428.977776 $21448.8800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 157 164 737.019052 $36851.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 44 50 168.426188 $1684.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 15 88.266663 $6305.7700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 8 8 39.752380 $2839.9100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 24 25 74.678570 $5335.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 8 8 20.259523 $1447.3400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 6 6 27.944444 $1996.3500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 18 19 85.761905 $6126.8300 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5264 EARMOLD 1 1 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 13 63.514286 $4537.4500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 11 11 59.038095 $4217.7000 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 19 19 89.338096 $6382.3200 $71.4400
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Subtotal (Total Children Is Unduplicated) 383 597 2041.314279 $120048.9300 $58.8100
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Total 652 2073.975393 $120744.0200 $58.2200
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Number of Children (Unduplicated) With at Least One Authorization 396