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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2524 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 54 55 90.800001 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 54 55 90.800001 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 4.133333 $478.6800 $115.8100
EXIT -EXIT EXIT ASSESSMENT 5 5 16.857143 $842.8600 $50.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 0.177778 $9.2200 $51.8600
MED -99204 OUTPATIENT VISIT, NEW, 45 MINS 1 1 0.888889 $99.4900 $111.9200
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 20 21 35.600002 $5063.4200 $142.2300
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Subtotal (Total Children Is Unduplicated) 29 33 57.657145 $6493.6500 $112.6300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 6.599999 $330.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 221 232 120.091869 $6004.6800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 31 31 15.569050 $778.4600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 121 127 59.269459 $1481.7400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 12 12 8.566666 $428.3300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 3 3 3.916667 $195.8400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 15 18 17.023811 $425.6000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 5.733334 $286.6700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 1.833333 $91.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 8 9.383334 $234.5900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 1.550000 $77.5000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.116667 $27.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 4.383333 $219.1700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.966667 $48.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 6.914287 $172.8600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 22 23 544.000000 $13600.0100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 23 23 475.142857 $11878.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 648 715 4134.761906 $206738.0600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 26 29 158.590480 $7929.5200 $50.0000
INTR -T1013 INTERPRETER 26 26 115.250000 $5762.5000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 738 863 5001.452381 $50014.5100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 47 216.330950 $15567.1900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 6 7 24.714285 $1778.4300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 14 15 78.674999 $4531.6800 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 4.928571 $283.8900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 46 49 202.734524 $14588.7700 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 17.178572 $1236.1600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 9 10 31.321429 $1802.8600 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 3.642857 $209.6900 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 4 4 3.133333 $719.4400 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.000000 $1377.6600 $459.2200
SENS -V5264 EARMOLD 17 18 26.155556 $474.2000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 99 112 512.121426 $36852.2500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 17 18 64.338096 $4629.7700 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.350000 $20.1600 $57.6000
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 26.428571 $368.9400 $13.9600
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Subtotal (Total Children Is Unduplicated) 901 2436 11910.169269 $396630.8300 $33.3000
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Total 2524 12058.626415 $403124.4800 $33.4300
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Number of Children (Unduplicated) With at Least One Authorization 955