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: 07-01-23 and 09-30-23 Date of Report: 10-10-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1107 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 15 15 17.544446 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 17.544446 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 8 8 8.000000 $388.0000 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.366667 $8.6800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.494444 $7.2600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 41 41 19.777779 $436.5000 $22.0700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.366667 $7.7200 $21.0400
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 5.857143 $301.1100 $51.4100
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Subtotal (Total Children Is Unduplicated) 52 55 36.862700 $1250.6700 $33.9300
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.666667 $28.2700 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 5 6 5.433333 $27166.5000 $4999.9700
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.133333 $262.4900 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 11 23.392856 $1169.6500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 7 7 5.633333 $281.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 1.483334 $74.1700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 3 2.788889 $139.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 39 42 49.894442 $2494.7100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 5.000000 $250.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 25.936508 $1296.8300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 2 2 2.666666 $133.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 30 32.605555 $1630.2800 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 28.828572 $1441.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 243 263 1257.603966 $62880.1500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 17 17 58.414286 $2920.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 380 472 2084.375393 $25012.4900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 35 38 248.214289 $17861.4900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 4.000000 $287.8400 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 14 14 91.238097 $6565.4900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 32 33 195.566666 $14072.9700 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 9 10 57.057143 $4105.8300 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.733333 $336.7500 $459.2000
SENS -V5264 EARMOLD 1 1 0.733333 $13.2900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 33 139.509524 $10039.1000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.733333 $196.6900 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 17 17 89.482539 $6439.1500 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.611111 $259.8500 $71.9600
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Subtotal (Total Children Is Unduplicated) 414 1037 4418.736501 $187360.5700 $42.4000
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Total 1107 4473.143647 $188611.2500 $42.1700
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Number of Children (Unduplicated) With at Least One Authorization 426