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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2418 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 42 43 65.461907 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 43 65.461907 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $115.8100
EXIT -EXIT COS Exit 2 2 3.000000 $150.0000 $50.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 27 28 26.499999 $3769.0800 $142.2300
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Subtotal (Total Children Is Unduplicated) 29 32 31.499999 $4150.7000 $131.7700
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.200000 $83.2200 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $694.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 171 188 129.834014 $6491.7200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 62 69 58.890478 $2944.5400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 130 134 64.114725 $1602.8700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 21 22 39.150000 $1957.5000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 7 9 13.321429 $666.0700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 11 11 12.783332 $319.5800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 21.450000 $1072.5000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 5 5 8.704762 $435.2400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 7 7 7.983333 $199.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 4.400000 $220.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 4 8.211904 $205.3000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 3.516667 $175.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.033333 $50.8300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 36 37 896.142859 $22403.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 20 20 574.857142 $14371.4300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 3.428571 $171.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 18.142857 $907.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 603 688 4066.480958 $203324.0600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 36 38 219.923811 $10996.2000 $50.0000
INTR -T1013 INTERPRETER 51 68 233.107143 $11655.3600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 643 771 4564.033335 $54768.4100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 37 192.390477 $13844.4100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 8 8 54.479367 $3920.3300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 11 11 54.864286 $3160.1800 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 4.285715 $246.8600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 43 48 234.980952 $16909.2400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 8 8 30.071429 $2163.9300 $71.9600
PHY -97110HM PT SESSION BY PT ASST 7 8 21.535715 $1239.5900 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 15.428572 $888.0700 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 18 19 24.799999 $449.6200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 79 443.666670 $31926.2300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 14 14 51.107143 $3677.6700 $71.9600
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Subtotal (Total Children Is Unduplicated) 864 2343 12085.320978 $415291.4100 $34.3600
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Total 2418 12182.282884 $419442.1100 $34.4300
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Number of Children (Unduplicated) With at Least One Authorization 901