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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1258 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 29 29 25.565081 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 0.488889 $18.0900 $37.0000
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Subtotal (Total Children Is Unduplicated) 30 30 26.053970 $18.0900 $0.6900
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 2.000000 $239.2000 $119.6000
EXIT -EXIT EXIT ASSESSMENT 6 6 12.000000 $600.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 7 7 14.000000 $839.2000 $59.9400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 1.188889 $59.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 10 7.744446 $387.2300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 2.243836 $536.7400 $239.2100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 91 99 12.147755 $607.5300 $50.0100
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 12 13 0.259726 $6.5000 $25.0400
CONIF -CONIF CONSULT, ITDS FACE TO FACE 11 12 12.666667 $633.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 1.516667 $37.9200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.483333 $124.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.066667 $1.6700 $25.0100
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 16.266666 $813.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 2.850000 $71.2500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 12 13 17.314841 $865.7500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.450000 $11.2500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 38 40 903.285715 $22582.1400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 260 272 1589.323816 $79466.1200 $50.0000
INTR -T1013 INTERPRETER 25 27 57.176190 $2858.8100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 369 453 2456.967788 $24569.6600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 47 150.411907 $10745.4200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 8 19.292857 $1103.5500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 61 66 201.378571 $14386.4700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 13 13 36.224999 $2070.6200 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 0.654795 $42.5700 $65.0100
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 4.000000 $948.4800 $237.1200
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.079452 $18.8500 $237.2600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 2 2 0.164384 $77.9700 $474.2900
SENS -V5264 EARMOLD 12 12 14.088888 $253.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 78 89 326.340476 $23313.7700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 7 79.428571 $1102.4700 $13.8800
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Subtotal (Total Children Is Unduplicated) 467 1221 5917.017902 $192696.6000 $32.5700
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Total 1258 5957.071872 $193553.8800 $32.4900
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Number of Children (Unduplicated) With at Least One Authorization 495