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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1198 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 34 34 34.419843 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 34 34 34.419843 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.000000 $347.4300 $115.8100
EXIT -EXIT COS Exit 81 81 81.000000 $4050.0000 $50.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
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Subtotal (Total Children Is Unduplicated) 84 85 88.000000 $4637.1100 $52.6900
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 11 12 22.087300 $1531.7500 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 75 77 64.234015 $3211.7100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 37 37 28.212264 $1410.6200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 30 30 29.560914 $739.0300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 2.200000 $110.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.066667 $103.3400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.133333 $6.6700 $49.9900
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 5 6 181.714285 $4542.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 322 360 2210.133361 $119347.1800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 24 25 141.514286 $7641.7800 $54.0000
INTR -T1013 INTERPRETER 69 102 345.500001 $17275.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 334 381 2337.657172 $28051.8800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 27.285715 $2218.8700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.142857 $269.7900 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 6 7 42.250000 $3435.7800 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 17.321428 $1408.5800 $81.3200
PHY -97110HM PT SESSION BY PT ASST 2 2 9.142857 $595.3900 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 4 4 25.857143 $1683.8200 $65.1200
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 2.000000 $229.6200 $114.8100
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5264 EARMOLD 6 7 4.266666 $77.3500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 11 57.071429 $4641.0500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 15.285714 $1243.0400 $81.3200
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Subtotal (Total Children Is Unduplicated) 412 1079 5570.637407 $200004.7200 $35.9000
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Total 1198 5693.057250 $204641.8300 $35.9500
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Number of Children (Unduplicated) With at Least One Authorization 514