Summary Report for FSPSAs Initiated During the Report Period Center: 53
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: 01-01-21 and 03-31-21 Date of Report: 05-04-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 700 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 10 10 15.577778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 10 15.577778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 2 2 1.038889 $50.3900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.000000 $225.9600 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.4900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.372222 $19.0300 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 28 28 14.099999 $334.1700 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.238889 $20.2700 $84.8400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.161111 $7.2500 $45.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 43 43 22.911110 $730.5500 $31.8900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 10.428571 $52143.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 51.571429 $2578.5700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 3.988889 $917.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 10 6.505556 $325.2800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 15 16 11.276190 $563.8100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.583333 $29.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 8 8 19.126192 $956.3200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 5.133333 $128.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 16 16.738888 $836.9400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 35 35 27.288890 $1364.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 6 6 6.655556 $166.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 2.655556 $132.7800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 10 10 22.492857 $1124.6500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 13 10.771431 $538.5800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 17 19 14.366669 $718.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 2.983333 $74.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 94 99 402.163084 $20108.1400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 195 209 929.158717 $46457.9400 $50.0000
INTR -T1013 INTERPRETER 1 1 0.700000 $35.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 30 35 89.421427 $894.2100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 17 55.695238 $3978.8700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 8 8 53.552381 $3825.7800 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 13.085714 $934.8400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 31 32 117.725396 $8410.3200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 9.285714 $663.3800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 5 5 22.457143 $1604.3400 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 1.000000 $71.4400 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 23 23 90.271426 $6448.9800 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.322222 $146.9200 $455.9700
SENS -V5264 EARMOLD 1 1 0.644444 $11.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 9 14.904760 $1064.7800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 13 13 70.480953 $5035.1600 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.400000 $100.0200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 26 26 92.090474 $6578.9600 $71.4400
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Subtotal (Total Children Is Unduplicated) 426 647 2177.925766 $168994.3100 $77.5900
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Total 700 2216.414654 $169724.8700 $76.5800
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Number of Children (Unduplicated) With at Least One Authorization 438