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: 10-01-22 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 1449 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 26 26 32.134920 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 26 26 32.134920 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 5.633333 $652.3900 $115.8100
EXIT -EXIT EXIT ASSESSMENT 3 3 11.123810 $556.1900 $50.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 0.822222 $42.6300 $51.8500
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 17 17 20.955554 $2980.4900 $142.2300
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Subtotal (Total Children Is Unduplicated) 21 25 38.534919 $4231.7000 $109.8100
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $694.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 152 159 89.330613 $4466.5800 $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 81 84 50.515168 $1262.8800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 8 9 16.430953 $821.5500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 10.580953 $264.5300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 4.000000 $200.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 7.446429 $186.1600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 5.066667 $253.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.166667 $54.1700 $25.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.207143 $30.1800 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 10 10 239.714285 $5992.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 10 10 363.428571 $9085.7200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 3.747619 $187.3800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 386 431 2653.695251 $132684.6800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 18 19 117.057142 $5852.8600 $50.0000
INTR -T1013 INTERPRETER 26 27 105.749999 $5287.5000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 413 475 2967.780968 $29677.7900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 23 132.214286 $9514.1400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 24.396429 $1755.5600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 4 10.704761 $616.6000 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.857143 $567.7700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 29 33 154.481548 $11116.4700 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 6.571429 $472.8800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 5.821428 $335.0800 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 14.250000 $820.2300 $57.5600
SENS -V5060 BEHIND EAR HEARING AID 4 4 5.633333 $1293.4600 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.000000 $1377.6600 $459.2200
SENS -V5264 EARMOLD 12 12 16.011110 $290.2800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 33 234.142858 $16848.9100 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 10 11 68.050000 $4896.8800 $71.9600
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Subtotal (Total Children Is Unduplicated) 582 1398 7333.643627 $247288.4700 $33.7200
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Total 1449 7404.313466 $251520.1700 $33.9700
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Number of Children (Unduplicated) With at Least One Authorization 602