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: 01-01-23 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 1685 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 29 29 34.228573 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 34.228573 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.333333 $38.6000 $115.8000
EXIT -EXIT EXIT ASSESSMENT 2 2 4.000000 $200.0000 $50.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 13 13 8.022220 $1140.9700 $142.2300
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Subtotal (Total Children Is Unduplicated) 15 16 12.355553 $1379.5700 $111.6600
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 171 174 99.386489 $4969.3800 $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 100 102 52.968399 $1324.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 11 11 16.922221 $846.1100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 2 2 1.400000 $70.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 9 16.485715 $412.1500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 8.000000 $400.0000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 2.300000 $115.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.333334 $83.3400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 0.199999 $10.0000 $49.9800
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 2 2 2.100000 $105.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 4 4 2.809524 $70.2400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.766667 $38.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 10.485714 $262.1400 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 11 11 296.285715 $7407.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 149.714287 $3742.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 481 529 3002.642855 $150132.3200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 15 15 85.866667 $4293.3400 $50.0000
INTR -T1013 INTERPRETER 22 30 163.178571 $8158.9300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 520 588 3386.104760 $33861.0800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 25 93.234921 $6709.1800 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 4 22.107144 $1590.8300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 5 6 22.885714 $1318.2200 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 3 3 11.857143 $682.9700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 23 24 132.734525 $9551.5800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 9.464286 $681.0400 $71.9600
PHY -97110HM PT SESSION BY PT ASST 9 11 40.114288 $2308.9700 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 5.000000 $287.8000 $57.5600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 8 8 5.255555 $95.2800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 35 231.571425 $16663.8900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 8 31.964286 $2300.1400 $71.9600
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Subtotal (Total Children Is Unduplicated) 665 1640 7914.145760 $259432.5900 $32.7800
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Total 1685 7960.729886 $260812.1600 $32.7600
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Number of Children (Unduplicated) With at Least One Authorization 692