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: 07-01-22 and 09-30-22 Date of Report: 10-19-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 944 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 13 13 12.599207 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 13 13 12.599207 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 3 4 1.811112 $87.8400 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 2.150000 $41.9500 $19.5100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 64 64 41.859525 $923.8400 $22.0700
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.188889 $8.5600 $45.3200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 13.552381 $717.3300 $52.9300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 71 75 59.561907 $1779.5200 $29.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 4.322222 $21611.0000 $4999.9700
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 1.494444 $346.1300 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2 2 0.571428 $28.5700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 2.285714 $114.2900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.233333 $61.6700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.450000 $72.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 37 57.088890 $2854.4500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 20 20 17.466668 $873.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 9.898413 $247.4600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 24.793651 $1239.6800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 6 6 22.030952 $1101.5500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 14 25.007935 $1250.3900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 11 11 10.850001 $542.5100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.000000 $25.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 10 10 283.761905 $14188.1000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 135 146 788.723814 $39436.2100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 119 124 554.241268 $27712.0600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 230 299 1471.312700 $14713.1300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 12 13 58.426983 $4204.4000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 7.433333 $534.9000 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 12 13 85.985714 $6187.5200 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 4 4 7.885715 $567.4500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 17 18 122.269842 $8798.5500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 10.000000 $719.6000 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 15 15 86.095238 $6195.4100 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 6 6 17.980952 $1293.9100 $71.9600
SENS -V5264 EARMOLD 1 1 0.700000 $12.6900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 34 187.793648 $13513.6400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 23.876191 $1718.1200 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 13 14 86.757143 $6243.0500 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 21 21 71.261905 $5128.0100 $71.9600
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 383 856 4044.000002 $181535.2700 $44.8900
-------------------------------------------------------------------------------------------------------------------------------------
Total 944 4116.161116 $183314.7900 $44.5400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 397