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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1796 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 5 5 4.850001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 4.850001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 68 98 82.920637 $4021.6600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.222222 $236.8700 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.055556 $1.0800 $19.5300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.055556 $1.3200 $23.6900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.055556 $0.8200 $14.6900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.055556 $1.2300 $22.0900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.055556 $0.4000 $7.2100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.055556 $1.6100 $28.9400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.055556 $2.5100 $45.1100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.055556 $0.7700 $13.8200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.055556 $22.2100 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 0.361112 $16.3700 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.361112 $41.8300 $115.8400
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 75 118 91.365087 $4485.6100 $49.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 18 23.511111 $117555.5000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 215 254 198.775396 $9938.7600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 23 25 25.200000 $1260.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 45 48 39.876983 $1993.8500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 100 104 87.850003 $4392.5200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.900000 $45.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 0.194444 $4.8600 $24.9900
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 67 50.200001 $2510.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 150 160 110.622218 $5531.0900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.666667 $33.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.138889 $3.4700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 1.571429 $78.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 27 28 151.484130 $7574.2100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 27.761905 $1388.1000 $50.0000
INTR -T1013 INTERPRETER 1 1 7.857143 $392.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 515 927 3029.645254 $30296.4400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 7 7 20.333333 $1463.1800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 4 4 16.977778 $1221.7200 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 19.571428 $1408.3600 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 1.066667 $76.7600 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 2 0.361112 $165.8700 $459.3300
SENS -V5264 EARMOLD 1 2 0.361112 $6.5500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 53.904762 $3878.9800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 8.266667 $594.8700 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 11.447619 $823.7700 $71.9600
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Subtotal (Total Children Is Unduplicated) 534 1673 3888.546051 $192638.6000 $49.5400
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Total 1796 3984.761139 $197124.2000 $49.4700
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Number of Children (Unduplicated) With at Least One Authorization 540