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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1376 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 39 40 17.011107 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 39 40 17.011107 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.633333 $100.7900 $61.7100
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $231.6200 $115.8100
EXIT -EXIT COS Exit 103 103 102.142857 $5107.1500 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 107 108 109.776190 $5709.4000 $52.0100
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 15 15 17.522221 $1215.1600 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.055556 $3.8600 $69.4100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 70 70 63.328696 $3166.4400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 40 41 31.699273 $1584.9700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 22 22 14.688852 $367.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 3 2.600000 $130.0000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 2.066667 $103.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.671429 $66.7900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 1.800000 $90.0000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 3 3 4.066667 $203.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 3 1.833334 $91.6700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 2.600000 $130.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.600000 $15.0000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 12 13 345.714285 $8642.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 4.571429 $123.4300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 358 403 2218.623789 $119805.7200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 28 35 202.257145 $10921.8700 $54.0000
INTR -T1013 INTERPRETER 84 129 309.421428 $15471.0700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 367 424 2322.980933 $27875.7800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 11.142857 $906.1300 $81.3200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 3.642857 $237.2300 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 10 11 58.500000 $4757.2100 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 1.419842 $115.4700 $81.3200
PHY -97110HM PT SESSION BY PT ASST 6 6 13.142857 $855.8700 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 4 6 24.142857 $1572.1800 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $459.2200 $229.6100
SENS -V5264 EARMOLD 6 6 7.588889 $137.5900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 9 59.071428 $4803.6800 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 9 41.000000 $3334.1100 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 497 1228 5770.753291 $207187.1700 $35.9000
-------------------------------------------------------------------------------------------------------------------------------------
Total 1376 5897.540588 $212896.5600 $36.1000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 536