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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 2093 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 36 36 57.213492 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 36 36 57.213492 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
EXIT -EXIT COS Exit 2 2 3.000000 $150.0000 $50.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 7 7 9.544444 $1357.5000 $142.2300
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Subtotal (Total Children Is Unduplicated) 10 10 13.544444 $1623.3100 $119.8500
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 17 17 25.484129 $1767.3300 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 5.988889 $415.3300 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 166 180 126.778210 $6338.9400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 61 65 65.711906 $3285.6100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 126 128 61.272523 $1531.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 10 10 14.700000 $735.0000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 4 5 10.647620 $532.3900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.266667 $31.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 14.964287 $748.2200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 2.700000 $135.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.266667 $31.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 12.916666 $645.8300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 3.533333 $176.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.116667 $27.9200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 18 20 644.571428 $16114.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 227.999997 $5700.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 3.857143 $192.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 518 614 3938.180994 $196908.8400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 38 40 185.000002 $9249.9900 $50.0000
INTR -T1013 INTERPRETER 49 68 265.457142 $13272.8700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 558 681 4330.195290 $51962.2800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 17 92.123809 $6629.2300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 12.397619 $892.1300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 11 12 66.471428 $3828.7500 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 3.857143 $222.1700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 35 37 253.235713 $18222.8600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 10.100000 $726.8000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 9 60.892858 $3504.9900 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 7 7 41.428572 $2384.6300 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 17 17 30.584127 $554.4900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 63 70 367.159528 $26420.7700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 54.214286 $3901.2500 $71.9600
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Subtotal (Total Children Is Unduplicated) 849 2047 10937.074643 $377322.1400 $34.5000
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Total 2093 11007.832579 $378945.4500 $34.4300
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Number of Children (Unduplicated) With at Least One Authorization 877