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
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1567 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 37 37 51.993651 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 37 37 51.993651 $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 EXIT ASSESSMENT 3 3 12.857143 $642.8600 $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 9 9 9.911112 $1409.6700 $142.2300
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Subtotal (Total Children Is Unduplicated) 14 16 25.834922 $2392.8500 $92.6200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 4.033333 $201.6700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 136 144 75.669899 $3783.5500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 16 16 7.590874 $379.5500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 80 82 39.244674 $981.1200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 9 9 5.549999 $277.5000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.966667 $48.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 5 3.209524 $80.2400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.500000 $125.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 3 0.750000 $18.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 1.550000 $77.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 3.033333 $151.6700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.966667 $48.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.216667 $55.4200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 13 14 351.428571 $8785.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 323.428570 $8085.7200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 435 482 2775.038100 $138751.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 19 21 111.780956 $5589.0500 $50.0000
INTR -T1013 INTERPRETER 23 23 100.035714 $5001.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 473 544 3121.304769 $31213.0300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 22 109.414285 $7873.4500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 6 7 24.714285 $1778.4300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 4 16.642856 $958.6300 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 30 33 138.710715 $9981.6100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 10.857143 $781.2800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 3 3 13.750000 $791.4500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 3.642857 $209.6900 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 6 6 3.977778 $72.1200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 42 201.402379 $14492.9200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 11 11 35.088097 $2524.9400 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.350000 $20.1600 $57.6000
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Subtotal (Total Children Is Unduplicated) 579 1514 7494.848712 $244981.3400 $32.6900
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Total 1567 7572.677285 $247374.1900 $32.6700
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Number of Children (Unduplicated) With at Least One Authorization 615