Summary Report for FSPSAs Ending During the Report Period Center: 06
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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2343 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 52 54 67.468256 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 52 54 67.468256 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.866667 $444.6700 $115.0000
EXIT -EXIT EXIT ASSESSMENT 23 23 46.000000 $2300.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.104110 $1.5600 $15.0000
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Subtotal (Total Children Is Unduplicated) 27 27 49.970777 $2746.2300 $54.9600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 6 6 3.733333 $186.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 23 24 27.644445 $1382.2300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 7.000000 $1610.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 108 114 30.261010 $1513.1800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 7 7 3.022224 $151.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 90 92 34.575334 $864.4100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 9 9 11.100001 $555.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 4.083333 $102.0800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.466667 $173.3400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 1.133333 $56.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 1.733332 $43.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.433334 $71.6700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.150000 $57.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 3.200000 $160.0000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 1.150000 $57.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.266667 $106.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 49 51 1180.999997 $29525.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 611 665 4176.076205 $208803.7800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 21 98.142858 $4907.1400 $50.0000
INTR -T1013 INTERPRETER 18 19 146.499999 $7325.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 735 860 5490.577004 $54905.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 41 166.966667 $11928.0900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 9 10 39.709523 $2836.8500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 16 17 66.228571 $3788.2800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 6 7 26.214286 $1499.4500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 53 58 197.926184 $14139.8600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 12 14 33.652382 $2404.1300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 12 37.142857 $2123.0800 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 3.214286 $183.7300 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.197260 $77.8200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5060 BEHIND EAR HEARING AID 3 3 3.866667 $881.6100 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 7 7 7.000000 $3192.0000 $456.0000
SENS -V5264 EARMOLD 21 22 21.566666 $388.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 142 151 625.640477 $44695.7400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 17 17 49.459525 $3533.3800 $71.4400
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Subtotal (Total Children Is Unduplicated) 896 2262 12513.034427 $409344.2600 $32.7100
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Total 2343 12630.473460 $412090.4900 $32.6300
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Number of Children (Unduplicated) With at Least One Authorization 947