Summary Report for FSPSAs Initiated During the Report Period Center: 54
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: 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 1991 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 9 9 10.344443 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 10.344443 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 78 91 53.794442 $2609.0200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 15 16 12.983333 $723.3000 $55.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.666667 $15.6700 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.800000 $11.6600 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 7 7 2.477777 $58.2300 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.800000 $7.8300 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.800000 $22.9800 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.144444 $6.4600 $44.7500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 2.500001 $212.1100 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.133333 $15.5400 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 2.083333 $43.5200 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 16.067461 $723.0400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.166667 $134.1700 $115.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 5.000000 $250.0000 $50.0000
SCREEN-T1023 SCREENING 2 2 2.155556 $107.7800 $50.0000
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Subtotal (Total Children Is Unduplicated) 113 146 102.573014 $4941.3100 $48.1700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 19 21.100000 $105500.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 1.255556 $62.7800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 1.622222 $111.7000 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 10 10 3.355556 $771.7900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 116 82.785515 $4139.2800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 115 154 115.772227 $5788.6400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 32 36 42.420633 $2121.0300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 45 55 108.683333 $5434.1700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.888889 $22.2200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 68 56.886507 $2844.3300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 66 67 65.987303 $3299.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.488889 $12.2200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 26 34.337302 $1716.8700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 20 20 16.388891 $819.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 64 65 66.096828 $3304.8500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 87 91 77.184132 $3859.2400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 6 6 4.866666 $121.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 128 136 513.914279 $25695.7000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 247 257 1282.313707 $64115.7200 $50.0000
INTR -T1013 INTERPRETER 1 2 10.071429 $503.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 275 411 1180.661107 $11806.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 36 111.707143 $7980.3700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 10 10 38.750794 $2768.3600 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 3 3 4.628571 $330.6700 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 32 34 121.955552 $8712.5100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 34 37 127.787301 $9129.1200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 5 6 35.714285 $2551.4200 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 7 7 14.028572 $1002.2100 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 30 33 93.401586 $6672.6100 $71.4400
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.800000 $182.4000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.333333 $607.9800 $455.9900
SENS -V5264 EARMOLD 5 5 4.188890 $75.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 48 52 155.571430 $11114.0100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 8 20.059524 $1433.0600 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 10 15.633333 $1116.8400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 38 42 183.589680 $13115.6600 $71.4400
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Subtotal (Total Children Is Unduplicated) 519 1836 4616.230965 $308843.8100 $66.9000
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Total 1991 4729.148422 $313785.1100 $66.3500
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Number of Children (Unduplicated) With at Least One Authorization 527