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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1572 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 32 33 50.523811 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 33 50.523811 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT COS Exit 1 1 2.000000 $100.0000 $50.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 14 15 16.033334 $2280.4300 $142.2300
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Subtotal (Total Children Is Unduplicated) 15 16 18.033334 $2380.4300 $132.0000
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.200000 $83.2200 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 107 116 82.587246 $4129.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 35 41 38.368255 $1918.4200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 81 84 42.276786 $1056.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 15 16 33.450000 $1672.5000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 5 6.971429 $348.5700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 7.299999 $182.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 8 8 17.566667 $878.3400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 4.738095 $236.9000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 3.983333 $99.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 2.500000 $125.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 3 6.728571 $168.2200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 3.516667 $175.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.033333 $50.8300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 23 24 603.142859 $15078.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 12 317.714286 $7942.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 3.428571 $171.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 18.142857 $907.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 419 474 2761.404768 $138070.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 27 160.647620 $8032.3900 $50.0000
INTR -T1013 INTERPRETER 37 51 168.357143 $8417.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 435 516 2997.214294 $35966.5800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 22 112.069050 $8064.4900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 31.484128 $2265.6000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 7 7 32.064286 $1846.9000 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 0.714286 $41.1400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 21 24 133.107142 $9578.4100 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 5 5 17.714286 $1274.7100 $71.9600
PHY -97110HM PT SESSION BY PT ASST 4 5 12.000001 $690.7200 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 10.714286 $616.7200 $57.5600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 11 12 17.333334 $314.2500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 28 29 159.711907 $11492.8500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 27.214286 $1958.3300 $71.9600
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Subtotal (Total Children Is Unduplicated) 568 1523 7841.399771 $265239.0900 $33.8300
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Total 1572 7909.956916 $267619.5200 $33.8300
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Number of Children (Unduplicated) With at Least One Authorization 597