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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2280 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 61 61 61.787302 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 61 61 61.787302 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 5.000000 $575.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 15 15 30.000000 $1500.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.438965 $6.5800 $15.0000
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Subtotal (Total Children Is Unduplicated) 21 22 35.438965 $2081.5800 $58.7400
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.900000 $145.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 32 32 35.644444 $1782.2200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 114 118 33.490176 $1674.6400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 8 8 3.316668 $165.8400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 92 95 36.850334 $921.2900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 8 8 9.533332 $476.6600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 11 11 14.466667 $361.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 8.333332 $416.6600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.233333 $130.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 3.816666 $190.8300 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.383333 $19.1700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 5.849999 $292.5000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.383333 $19.1700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 8.600000 $215.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 22 517.857141 $12946.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 658 704 4328.957145 $216448.0000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 27 165.071429 $8253.5800 $50.0000
INTR -T1013 INTERPRETER 15 16 115.357142 $5767.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 749 841 5334.019851 $53340.2300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 48 200.516668 $14324.9100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 6 6 15.928571 $1137.9400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 9 24.214287 $1385.0500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 5 13.785715 $788.5500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 41 46 224.271430 $16021.9400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 7 10 25.350001 $1811.0000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 11 49.928572 $2853.9100 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 2 3.357143 $191.9000 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.911111 $59.2200 $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 3.000000 $684.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 24 24 26.922222 $484.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 97 105 447.142865 $31943.8500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 12 12 56.285715 $4021.0400 $71.4400
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Subtotal (Total Children Is Unduplicated) 889 2197 11726.678625 $380761.4500 $32.4700
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Total 2280 11823.904892 $382843.0400 $32.3800
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Number of Children (Unduplicated) With at Least One Authorization 952