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 1329 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 73 86 48.172219 $2336.3400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.322222 $17.9500 $55.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.666667 $15.6700 $23.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.144444 $3.3900 $23.4900
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.144444 $6.4600 $44.7500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.955556 $81.0700 $84.8400
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 12.123017 $545.5400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.355556 $40.8900 $115.0100
EXIT -EXIT EXIT ASSESSMENT 4 4 5.000000 $250.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 85 101 67.884125 $3297.3200 $48.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 12 18.644445 $93222.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 0.455556 $22.7800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 0.527778 $36.3400 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 0.250000 $57.5000 $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 10 11 42.760318 $2138.0200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 21 22 156.925398 $7846.2800 $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 3 3 15.100000 $1078.7400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 4 4 19.619048 $1401.5800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 9 9 42.073016 $3005.7000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 5 5 19.477778 $1391.4900 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.333333 $151.9800 $455.9500
SENS -V5264 EARMOLD 2 2 1.622223 $29.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 13 56.171429 $4012.8700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 4 3.494445 $249.6500 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.533333 $109.5400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 22.361904 $1597.5300 $71.4400
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Subtotal (Total Children Is Unduplicated) 458 1219 2264.869655 $162145.2200 $71.5900
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Total 1329 2343.098223 $165442.5400 $70.6100
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Number of Children (Unduplicated) With at Least One Authorization 467