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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1571 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 35 35 26.061905 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 35 26.061905 $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 3 3 6.000000 $300.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 4 4 7.000000 $415.0000 $59.2900
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 12 12 15.444443 $772.2200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 92 21.397706 $1069.9700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 1.750000 $87.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 72 72 24.228582 $605.7400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 8.933334 $446.6700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.700000 $35.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 4.366667 $109.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 5.000000 $250.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.266667 $6.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 7.666666 $383.3300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.700000 $35.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.100000 $102.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 23 685.714287 $17142.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 461 510 2926.742823 $146337.2400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 14 73.657142 $3682.8700 $50.0000
INTR -T1013 INTERPRETER 42 43 169.071428 $8453.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 518 595 3355.638054 $33556.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 28 29 98.809525 $7058.9600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 5.000000 $357.2000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 7 24.142858 $1380.9700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 2.142857 $122.5700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 26 28 70.364286 $5026.8300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.714286 $336.7900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 11 13 36.749999 $2100.6400 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 10.142857 $579.7700 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 7 7 9.599999 $172.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 45 142.007143 $10145.0200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 8 9 33.428570 $2388.1400 $71.4400
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Subtotal (Total Children Is Unduplicated) 630 1532 7746.480179 $244118.3700 $31.5100
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Total 1571 7779.542084 $244533.3700 $31.4300
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Number of Children (Unduplicated) With at Least One Authorization 655