Summary Report for FSPSAs Initiated During the Report Period Center: 06
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 1772 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 55 55 80.511111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 55 55 80.511111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 2.000000 $230.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 30 30 67.142857 $3357.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 31 32 69.142857 $3587.1500 $51.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 5 5.000000 $25000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 6 8.366665 $418.3300 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 11 11 8.955556 $447.7800 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 74 75 13.709504 $685.5700 $50.0100
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 5 9.588097 $479.4100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 55 57 11.788887 $294.7700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 3.566666 $178.3300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 3.066667 $153.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 5.616667 $140.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 4 6.999999 $350.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 4.800000 $120.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 0.533333 $26.6700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 3.066667 $153.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 3.033333 $151.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.883333 $47.0800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 27 27 610.142856 $15253.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 394 415 2719.861868 $135993.2200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 42 44 291.133336 $14556.6600 $50.0000
INTR -T1013 INTERPRETER 28 31 107.714287 $5385.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 564 658 4496.109478 $44961.1200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 42 197.509527 $14110.0900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 8 9 45.642857 $3260.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 9 9 38.285715 $2189.9400 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 0.928571 $53.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 55 61 262.442858 $18748.9400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 8 8 50.857143 $3633.2400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 11 12 34.785714 $1988.3500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 3.515069 $228.4800 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 1 2 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 11 12 9.844445 $177.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 127 141 524.750001 $37488.1600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 20 20 87.928570 $6281.6300 $71.4400
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Subtotal (Total Children Is Unduplicated) 658 1685 9577.427669 $334784.8300 $34.9600
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Total 1772 9727.081637 $338371.9800 $34.7900
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Number of Children (Unduplicated) With at Least One Authorization 717