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: 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 2976 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 32 38 84.866667 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 4 18.533333 $685.7300 $37.0000
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Subtotal (Total Children Is Unduplicated) 35 42 103.400000 $685.7300 $6.6300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 10 9.011111 $437.0400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 14 12.833333 $724.9500 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.011111 $23.7500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 22 22 13.611111 $188.7900 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 109 118 95.461116 $2262.4400 $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 -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.744444 $63.1500 $84.8300
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 3 3 2.677778 $120.5000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 3.000000 $150.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 159 176 142.388893 $4082.1900 $28.6700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 14 36.584126 $182920.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 133.571429 $6678.5700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 2.527778 $181.0200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 34 37 30.833334 $7091.6800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 27 23.046826 $1152.3500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 46 49 42.672221 $2133.6200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 7.255556 $362.7800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 23 25 110.929365 $5546.4800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 11.177777 $279.4400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 73 189.315875 $9465.8000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 115 140 338.794439 $16939.7000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 16 17 48.922221 $1223.0500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 15 31.988889 $1599.4500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 41 53 190.943650 $9547.1900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 2 17.400000 $435.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 55 64 146.804763 $7340.2400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 77 89 183.897617 $9194.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 26 30 37.750001 $943.7500 $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 3 3 8.333333 $416.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 289 346 4262.492432 $213124.6300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 634 877 9885.629321 $494281.4700 $50.0000
INTR -T1013 INTERPRETER 1 1 3.733333 $186.6700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 152 207 1310.726188 $13107.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 59 405.711108 $28983.9800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 27 35 406.447619 $29036.6000 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 10 11 87.735712 $6267.8300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 103 147 1384.738880 $98925.7800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 20 26 309.744444 $22128.1300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 14 24 260.339682 $18598.6500 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 11 13 57.223809 $4088.0800 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 67 96 1140.114283 $81449.7700 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.333333 $607.9800 $455.9900
SENS -V5264 EARMOLD 5 5 7.155555 $128.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 46 55 394.907143 $28212.1800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 37 46 547.204759 $39092.3300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 14 14 72.031749 $5145.9700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 99 129 1319.146030 $94239.8300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.866667 $164.7100 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 9.733334 $135.1000 $13.8800
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Subtotal (Total Children Is Unduplicated) 1219 2758 23501.764580 $1442206.1900 $61.3700
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Total 2976 23747.553473 $1446974.1100 $60.9300
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Number of Children (Unduplicated) With at Least One Authorization 1238