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: 07-01-20 and 06-30-21 Date of Report: 07-15-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 3005 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 36 42 75.805555 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 16.400000 $606.8000 $37.0000
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Subtotal (Total Children Is Unduplicated) 39 45 92.205555 $606.8000 $6.5800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 12 12 9.844444 $477.4500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 11 9.833333 $555.4800 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.4900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 14 14 10.716667 $148.6400 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 87 102 84.438892 $2001.2100 $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 -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.011111 $51.6400 $51.0700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.027778 $23.0200 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 3.466667 $156.0000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 3.000000 $150.0000 $50.0000
SCREEN-T1023 SCREENING 3 3 7.555556 $377.7800 $50.0000
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Subtotal (Total Children Is Unduplicated) 132 153 133.894448 $4001.6300 $29.8900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 16 17.744444 $88722.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 5.788889 $289.4500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 1.561111 $111.7900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 30 31 28.322223 $6514.1300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 21 27 23.546826 $1177.3500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 44 47 36.249999 $1812.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 13.295237 $664.7600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 12 14 49.350001 $2467.5100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 20.361904 $509.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 81 88 205.845239 $10292.2600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 89 104 309.784124 $15489.2000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 16 16 45.522221 $1138.0500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 27 66.538890 $3326.9500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 35 42 139.466667 $6973.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 16.400000 $410.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 73 84 193.979365 $9698.9600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 67 77 162.149203 $8107.4400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 21 22 31.038890 $775.9800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 28.999999 $725.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 7 27.945237 $1397.2600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 422 486 4752.525774 $237626.2800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 511 684 8446.921412 $422346.1300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 350 431 2440.431731 $24404.3300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 64 77 632.807935 $45207.8000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 23 25 368.385715 $26317.4600 $71.4400
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 4.142857 $236.9700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 7 7 55.497617 $3964.7600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 78 112 1180.112695 $84307.2900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 45 49 500.049998 $35723.5600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 19 28 322.758730 $23057.8900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.285714 $473.6100 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.466667 $312.4800 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 3 3 32.428571 $2316.7000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 53 73 1045.357142 $74680.3100 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.046575 $21.2500 $456.2400
SENS -V5264 EARMOLD 3 4 5.104262 $91.8800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 45 58 524.557938 $37474.4500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 36 44 548.971426 $39218.5300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 69 92 1078.322225 $77035.3400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 14.733334 $204.5000 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 7.142857 $264.2900 $37.0000
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Subtotal (Total Children Is Unduplicated) 1135 2807 23402.941644 $1296493.0900 $55.4000
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Total 3005 23629.041647 $1301101.5200 $55.0600
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Number of Children (Unduplicated) With at Least One Authorization 1151