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: 07-01-21 and 09-30-21 Date of Report: 10-13-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 857 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 4 4 4.788890 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 1.833333 $67.8300 $37.0000
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Subtotal (Total Children Is Unduplicated) 5 5 6.622223 $67.8300 $10.2400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 5 5 4.027778 $195.3500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.000000 $169.4700 $56.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 0.950000 $13.1800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 23 23 13.300000 $315.2100 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.250000 $21.2100 $84.8400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.361111 $16.2500 $45.0000
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 39 39 23.888889 $832.7600 $34.8600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 8.599207 $42996.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 28.428571 $1421.4300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 9 9 4.405555 $1013.2700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 12 10.750000 $537.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 6 7 4.688889 $234.4500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 5.383333 $269.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 7 7 11.306349 $565.3200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.844444 $21.1100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 18 21.083332 $1054.1600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 41 41 44.482540 $2224.1300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 7.144445 $178.6100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 9.199999 $460.0000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 14 14 24.001587 $1200.0800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 16 16 14.984126 $749.2100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 25 25 33.033335 $1651.6800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 3.700000 $92.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 81 84 378.177781 $18908.8800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 213 231 1058.552380 $52927.6000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 80 97 337.716664 $3377.1600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 14 59.836508 $4274.7200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 9 9 38.971429 $2784.1100 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 9 11 25.552382 $1825.4600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 36 37 136.823809 $9774.6900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 11 43.807936 $3129.6200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 3 5.023810 $358.9100 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 7 7 31.585714 $2256.4800 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 33 34 111.642859 $7975.7800 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.722222 $329.3200 $455.9900
SENS -V5264 EARMOLD 1 1 1.444444 $26.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 17 63.274603 $4520.3400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 11 12 58.652382 $4190.1300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 12 15 63.185713 $4513.9700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 42 46 238.791273 $17059.2400 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.733333 $10.1800 $13.8800
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Subtotal (Total Children Is Unduplicated) 450 813 2887.530954 $192936.1700 $66.8200
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Total 857 2918.042066 $193836.7700 $66.4300
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Number of Children (Unduplicated) With at Least One Authorization 455