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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2176 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 5.900000 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 9.666666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 15.566666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 3.000000 $310.0800 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 86 104 83.605555 $4054.8700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 10.122223 $567.8600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 5 5 2.900000 $45.9400 $15.8400
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.083333 $1.9700 $23.6600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.083333 $15.9000 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 16 16 12.449999 $274.7700 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.555555 $4.8900 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.083333 $2.4100 $28.9100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.083333 $48.8400 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 0.794444 $10.9700 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.555555 $11.6900 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.472222 $28.8000 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.472222 $127.9900 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 0.472222 $35.4800 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 15 8.188889 $371.1200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.083333 $9.6500 $115.7600
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Subtotal (Total Children Is Unduplicated) 128 171 127.005551 $5923.2300 $46.6400
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 3 3 2.694444 $114.2700 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 30 36 48.911110 $244555.0000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 3.394444 $786.2100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 196 245 185.153176 $9257.6800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 13 16 10.561111 $528.0600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 50 54 44.162701 $2208.1500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 88 60.711108 $3035.5400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 4 4 4.363491 $218.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.666667 $16.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 71 72 55.266665 $2763.3300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 163 172 111.715869 $5585.7800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 0.266666 $13.3300 $49.9900
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.033334 $25.8400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 5 5 21.890476 $1094.5300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 340 375 1671.526204 $83576.3500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 28 29 139.450795 $6972.5400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 365 656 1760.523808 $21126.2900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 53 55 314.648414 $22642.1100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 6 7 39.425397 $2837.0500 $71.9600
OCCT -97530TL OT SESSION BY LICENSED OT 33 37 160.319053 $11536.5600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 26 28 88.930952 $6399.4600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 21.571429 $1552.2800 $71.9600
PHY -97110TL PT SESSION BY LICENSED PT 29 29 120.811111 $8693.5800 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.511111 $58.6800 $114.8100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 1.849999 $849.5100 $459.2000
SENS -V5264 EARMOLD 4 4 5.616666 $101.8300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 32 38 159.976186 $11511.8900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 14.714286 $1058.8400 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 22 22 68.198411 $4907.5600 $71.9600
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Subtotal (Total Children Is Unduplicated) 601 1996 5119.865084 $454052.0500 $88.6800
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Total 2176 5262.437301 $459975.2800 $87.4100
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Number of Children (Unduplicated) With at Least One Authorization 608