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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2436 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 48 48 42.089685 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 48 48 42.089685 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 9 9 18.000000 $900.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 2.000000 $30.0000 $15.0000
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Subtotal (Total Children Is Unduplicated) 12 12 21.000000 $1045.0000 $49.7600
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 3.088888 $154.4400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 18 18 19.211113 $960.5700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $690.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 113 116 29.707435 $1485.4900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 5 2.071429 $103.5700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 131 139 40.806769 $1020.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 14 14 8.716665 $435.8300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.800000 $40.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 17 17 12.800001 $320.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 8.016666 $400.8300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.333333 $16.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 4.516667 $112.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 2.233333 $111.6700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.650000 $32.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 8 8 6.933333 $346.6700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 1.450000 $72.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 9 9 5.150000 $128.7500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 4.000000 $100.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 43 46 1049.714288 $26242.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 615 690 4074.547617 $203727.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 24 147.790476 $7389.5200 $50.0000
INTR -T1013 INTERPRETER 45 47 174.642858 $8732.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 738 878 5309.428577 $53094.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 49 54 196.899999 $14066.5600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 8 9 29.928570 $2138.1000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 16 18 49.785713 $2847.7500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 5.214285 $298.2600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 55 58 217.895235 $15566.4200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 4 7.642857 $546.0100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 14 20 60.285713 $3445.9300 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 3 7.519047 $429.7900 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.000000 $195.0000 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 17 17 17.800002 $320.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 118 125 487.795233 $34848.1400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 18 21 69.714287 $4980.3900 $71.4400
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Subtotal (Total Children Is Unduplicated) 915 2376 12067.090389 $386655.3800 $32.0400
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Total 2436 12130.180074 $387700.3800 $31.9600
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Number of Children (Unduplicated) With at Least One Authorization 958