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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1416 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 41 42 55.326194 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 41 42 55.326194 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $231.6200 $115.8100
EXIT -EXIT COS Exit 109 110 87.250000 $4362.5000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 110 111 89.250000 $4594.1200 $51.4700
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 9 9 22.025397 $1527.4800 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 87 91 80.642782 $4032.1400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 33 34 27.997795 $1399.8900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 42 42 22.747186 $568.6800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 7.511111 $375.5600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 2.266667 $113.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 7.304762 $182.6200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.344444 $117.2200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 3.000000 $150.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.066667 $26.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 3.500000 $175.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.666666 $116.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 1.933333 $96.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 32 38 862.857152 $21571.4100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 2 28.571428 $771.4300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 376 431 2760.676223 $149076.5400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 27 28 172.114288 $9294.1900 $54.0000
INTR -T1013 INTERPRETER 42 57 328.109524 $16405.4700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 385 450 2855.700036 $34268.4100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 21.071429 $1713.5300 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.500000 $40.6600 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.714286 $567.4800 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 10.571429 $688.4100 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 10 11 43.615872 $3546.8500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 4 4 16.557143 $1346.4200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 5 5 35.300001 $2298.7400 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 4 4 34.428572 $2241.9900 $65.1200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 2.000000 $229.6200 $114.8100
SENS -V5264 EARMOLD 3 3 10.885714 $197.3600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 16 98.321429 $7995.5000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 18.285714 $1486.9900 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 470 1263 7496.287050 $262647.9100 $35.0400
-------------------------------------------------------------------------------------------------------------------------------------
Total 1416 7640.863244 $267242.0300 $34.9800
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 598