Summary Report for FSPSAs Ending During the Report Period Center: 54
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 2105 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 7 7 7.233334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 7.233334 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 76 85 53.544444 $2596.9000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 8.538889 $475.7000 $55.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 2.544444 $37.1000 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $47.0000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 2.544444 $24.9100 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 2.544444 $73.0800 $28.7200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 14 14 8.105555 $687.6700 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.377778 $5.1800 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 4.000000 $83.5600 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 4.877778 $219.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.888889 $332.2200 $115.0000
EXIT -EXIT EXIT ASSESSMENT 2 2 2.000000 $100.0000 $50.0000
SCREEN-T1023 SCREENING 2 2 1.255556 $62.7800 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.177778 $9.0800 $51.0600
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.177778 $9.0800 $51.0600
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Subtotal (Total Children Is Unduplicated) 114 145 95.577777 $4763.7600 $49.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 15 17.555555 $87777.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.922223 $46.1200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 12.668254 $633.4100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 1.047184 $72.1000 $68.8500
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 2.916666 $670.8200 $229.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 109 135 111.015472 $5550.7700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 101 138 111.861114 $5593.0700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 38 46 52.882537 $2644.1100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 36 49 53.488887 $2674.4400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 73 49.550791 $2477.5300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 52 54 48.811110 $2440.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.200000 $55.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 47 45.822223 $2291.1200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 21 21 15.538891 $776.9600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 88 90 65.729364 $3286.4600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 68 71 58.866664 $2943.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.833333 $45.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 118 125 567.126189 $28356.3100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 265 283 1266.743655 $63337.1600 $50.0000
INTR -T1013 INTERPRETER 1 1 2.500000 $125.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 303 523 1249.665081 $12496.6500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 26 30 127.188887 $9086.3600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 20 20 65.923015 $4709.5400 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 4 4 20.514286 $1465.5400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 33 35 149.896823 $10708.6200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 15 21 30.438890 $2174.5600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 11 13 43.509524 $3108.3300 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 3 3 10.916667 $779.8900 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 31 33 115.585713 $8257.4300 $71.4400
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.177778 $268.5400 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 2.077778 $947.4800 $456.0000
SENS -V5264 EARMOLD 4 4 3.188889 $57.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 20 22 67.759525 $4840.7400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 18 21 97.482540 $6964.1400 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 3.033334 $216.7100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 43 45 280.464284 $20036.3600 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 10.000000 $138.8000 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 2.333333 $86.3300 $37.0000
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Subtotal (Total Children Is Unduplicated) 559 1953 4770.236459 $298140.9600 $62.5000
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Total 2105 4873.047570 $302904.7100 $62.1600
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Number of Children (Unduplicated) With at Least One Authorization 565