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 1454 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 73 82 51.888889 $2516.6100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.588889 $23.1700 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.588889 $15.5600 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.588889 $45.6300 $28.7200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 4 4 1.494444 $126.7900 $84.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $20.8900 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.344444 $15.5000 $44.9900
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 82 96 61.494444 $2869.8500 $46.6700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 12.583333 $62916.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.155556 $7.7800 $50.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 12.446032 $622.3000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.161111 $11.0900 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 1.511111 $347.5500 $230.0000
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 16 16 101.156348 $5057.8200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 24 110.746033 $5537.3000 $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 3 3 6.000000 $428.6400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 5.088888 $363.5400 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.200000 $228.6100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 5.900000 $421.5000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 3.033333 $216.7000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 3 6.666667 $476.2700 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 2.533333 $180.9800 $71.4400
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.955556 $217.8800 $228.0100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.322222 $602.9200 $455.9900
SENS -V5264 EARMOLD 3 3 2.966667 $53.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 16.194446 $1156.9400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 5 16.771429 $1198.1500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 17.630952 $1259.5500 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 2.333333 $86.3300 $37.0000
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Subtotal (Total Children Is Unduplicated) 480 1351 2199.121817 $124792.5400 $56.7500
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Total 1454 2267.849595 $127662.3900 $56.2900
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Number of Children (Unduplicated) With at Least One Authorization 484