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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 854 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 8 8 14.766668 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 14.766668 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 4 4 4.000000 $194.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 1.500000 $35.2500 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 1.149999 $16.7700 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 38 38 19.394443 $455.7700 $23.5000
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Subtotal (Total Children Is Unduplicated) 50 50 27.044442 $757.4900 $28.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.000000 $100.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 4.994444 $1148.7100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 3 5 5.000000 $250.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 9 9 9.792857 $489.6500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.194444 $59.7200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 5 6 13.142857 $657.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 20 24.083333 $1204.1700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 26 26 30.421429 $1521.0700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.666666 $41.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 5.556350 $277.8200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 18 20 27.896826 $1394.8400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 11 11 11.900000 $595.0000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 19 19 14.212699 $710.6400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 4.016667 $100.4200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 85 90 416.692865 $20834.6300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 248 258 1250.193663 $62509.6700 $50.0000
INTR -T1013 INTERPRETER 1 1 2.857143 $142.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 88 98 358.297622 $3582.9800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 14 44.604763 $3186.5700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 11 12 49.657144 $3547.5100 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 11 11 28.123810 $2009.1600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 35 37 257.857144 $18421.3200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 8 8 28.909524 $2065.2900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 7 7 12.166668 $869.2000 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 7 7 13.880952 $991.6500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 14 14 52.823808 $3773.7300 $71.4400
SENS -V5264 EARMOLD 3 4 4.177777 $75.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 21 101.426983 $7245.9500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 14 15 67.547620 $4825.6000 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 10 10 54.863492 $3919.4400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 39 42 214.442861 $15319.7800 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 0.666667 $9.2500 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.933333 $68.4700 $13.8800
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Subtotal (Total Children Is Unduplicated) 476 796 3123.002411 $176949.0900 $56.6600
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Total 854 3164.813521 $177706.5800 $56.1500
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Number of Children (Unduplicated) With at Least One Authorization 483