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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1091 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.008333 $0.3100 $37.0600
SCONLY-SCONLY *SERVICE COORDINATION ONLY 8 8 11.855556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 11.863889 $0.3100 $0.0300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 8 4.022222 $195.0800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.714286 $96.1700 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 7 7 7.000000 $136.5700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.338889 $8.0200 $23.6700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 41 41 21.138887 $466.5300 $22.0700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.338889 $7.1300 $21.0400
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Subtotal (Total Children Is Unduplicated) 55 59 34.553173 $909.5000 $26.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 6.977778 $34889.0000 $5000.0200
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 17 13.327778 $666.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 5 3.142857 $157.1500 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 8 4.925002 $246.2600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.733333 $86.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 49 49 45.504763 $2275.2400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 5.000000 $250.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.916667 $22.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 22 24 23.555556 $1177.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 29 30 30.326983 $1516.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.083334 $102.0900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 15 15 56.578572 $2828.9300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 221 227 1151.271433 $57563.5200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 24 93.195243 $4659.7600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 352 474 1899.986515 $18999.8600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 31 145.257144 $10452.7200 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 12 13 52.342858 $3766.6000 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 12.104762 $871.0500 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 20 20 98.133333 $7061.6900 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 7 7 31.421430 $2261.0800 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 7.857143 $565.4000 $71.9600
SENS -V5264 EARMOLD 1 1 2.000000 $36.2600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 35 172.065075 $12381.8100 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 26.571428 $1912.0900 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 14 15 72.547619 $5220.5300 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.066667 $292.6400 $71.9600
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Subtotal (Total Children Is Unduplicated) 383 1023 3965.893273 $170495.3600 $42.9900
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Total 1091 4012.310335 $171405.1800 $42.7200
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Number of Children (Unduplicated) With at Least One Authorization 392