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 765 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 28 28 22.965081 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 28 28 22.965081 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 6 6 12.000000 $600.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 6 6 12.000000 $600.0000 $50.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.200000 $10.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 4.288890 $214.4500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.079452 $19.0200 $239.3400
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 15 17 109.857141 $5492.8600 $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 10 10 23.500001 $1678.8300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 4 5.135714 $293.7600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 22 23 72.335713 $5167.6600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.350000 $134.3300 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.561644 $36.5100 $65.0100
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.079452 $18.8500 $237.2600
SENS -V5264 EARMOLD 2 2 0.844444 $15.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 18 55.857142 $3990.4400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 76.785714 $1065.7900 $13.8800
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Subtotal (Total Children Is Unduplicated) 417 731 2933.041607 $53738.8500 $18.3200
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Total 765 2968.006688 $54338.8500 $18.3100
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Number of Children (Unduplicated) With at Least One Authorization 444