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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1597 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 38 34.155556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 37 38 34.155556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.666667 $77.2100 $115.8200
EXIT -EXIT EXIT ASSESSMENT 2 2 2.088889 $104.4500 $50.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 10 11 8.166668 $1161.5600 $142.2300
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Subtotal (Total Children Is Unduplicated) 12 14 10.922224 $1343.2200 $122.9800
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 0.988889 $49.4500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 166 173 103.532916 $5176.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 10 10 5.005556 $250.2800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 99 103 64.659669 $1616.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 12 12 13.283334 $664.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 2.200000 $110.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 4.766667 $119.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 8.233333 $411.6700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 2.200000 $110.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 6 6 7.027778 $351.3900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 4 2.426191 $60.6600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.583333 $29.1700 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 18 18 326.857146 $8171.4200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 14 286.857144 $7171.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 439 475 2850.866656 $142543.4600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 12 73.133332 $3656.6700 $50.0000
INTR -T1013 INTERPRETER 20 27 99.178570 $4958.9400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 482 539 3160.609512 $31606.1200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 26 26 106.823810 $7687.0300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 17.166667 $1235.3200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 6 6 10.490476 $604.2500 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 5.571428 $320.9100 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 25 26 106.204168 $7642.4500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 14.785715 $1063.9800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 9 11 23.111907 $1330.3200 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 12.250000 $705.1000 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 1.000000 $71.9600 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 7 8 6.055556 $109.7900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 29 137.035714 $9861.0900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 10 12 57.447617 $4133.9300 $71.9600
TRAV -TRAVS Travel by mile 1 1 6.000000 $2.6700 $0.4500
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Subtotal (Total Children Is Unduplicated) 570 1545 7519.353084 $242541.7900 $32.2600
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Total 1597 7564.430864 $243885.0100 $32.2400
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Number of Children (Unduplicated) With at Least One Authorization 607