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: 10-01-23 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 1341 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 24 24 43.963492 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 24 24 43.963492 $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 4 4 2.533333 $360.3100 $142.2300
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Subtotal (Total Children Is Unduplicated) 5 5 4.533333 $460.3100 $101.5400
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 12 12 13.711112 $950.8700 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.888889 $61.6500 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 103 111 82.423091 $4121.1800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 37 40 47.939683 $2396.9900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 78 80 39.454562 $986.3600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 7 8.083333 $404.1700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 3 3.666667 $183.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.266667 $31.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.516667 $175.8400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 2.700000 $135.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.266667 $31.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 11.533333 $576.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 3.533333 $176.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.116667 $27.9200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 13 15 460.571428 $11514.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 98.285713 $2457.1400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 3.857143 $192.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 351 409 2676.947647 $133847.2700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 30 32 163.142860 $8157.1300 $50.0000
INTR -T1013 INTERPRETER 37 54 218.635714 $10931.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 368 441 2911.242891 $34934.8800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 9 9 49.695239 $3576.0700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 10.714286 $771.0000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 8 9 52.499999 $3023.9900 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 3.857143 $222.1700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 16 17 110.328571 $7939.2500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 2.000000 $143.9200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 6 7 49.000000 $2820.4400 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 12.392857 $713.3400 $57.5600
SENS -V5264 EARMOLD 10 10 11.366666 $206.0800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 24 24 139.411908 $10032.0600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 27.642857 $1989.1800 $71.9600
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Subtotal (Total Children Is Unduplicated) 546 1312 7222.693593 $243732.8000 $33.7500
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Total 1341 7271.190418 $244193.1100 $33.5800
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Number of Children (Unduplicated) With at Least One Authorization 563