Summary Report for FSPSAs Ending During the Report Period Center: 54
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 2316 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 7 7 3.266666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 3.266666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 76 103 76.097624 $3690.7600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 22 22 17.333332 $972.3900 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.361111 $5.7200 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.5100 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.450000 $21.2900 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 33 33 25.112699 $554.2400 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.2000 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.9200 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.800000 $38.6700 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 1.472222 $30.9800 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.261111 $22.7000 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 15 12.744444 $577.5800 $45.3200
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Subtotal (Total Children Is Unduplicated) 131 187 142.632543 $6038.6900 $42.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 31 49.466667 $247333.5000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 3.216667 $745.0500 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 205 252 201.397222 $10069.8600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 20 30 24.672222 $1233.6100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 41 47 69.879369 $3493.9900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.566667 $14.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 99 101 76.891270 $3844.5600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 2.166667 $108.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 63 54.810321 $2740.5300 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.533333 $76.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 157 163 130.905556 $6545.2800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 1.227777 $61.3900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.033333 $0.8300 $24.9800
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 11.580953 $579.0500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 298 323 1455.320630 $72766.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 28 28 152.090477 $7604.5300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 489 879 2751.627787 $27516.2800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 33 157.788096 $11354.4400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 7 8 46.777779 $3366.1200 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 18 18 97.480952 $7014.7400 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 6.800000 $489.3300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 35 37 151.482541 $10900.6800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 9.342857 $672.3200 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 20 21 112.438096 $8091.0300 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 7.447620 $535.9400 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.722222 $82.9200 $114.8100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.911111 $1796.0600 $459.2200
SENS -V5264 EARMOLD 5 5 5.333332 $96.6900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 34 183.658729 $13216.0900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 6.842857 $492.4200 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 18 20 123.338098 $8875.4000 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.600000 $402.9800 $71.9600
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Subtotal (Total Children Is Unduplicated) 538 2122 5906.351208 $452120.7600 $76.5500
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Total 2316 6052.250417 $458159.4600 $75.7000
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Number of Children (Unduplicated) With at Least One Authorization 545