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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1442 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 35 37 47.099999 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 37 47.099999 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 12 12 24.000000 $1200.0000 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
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Subtotal (Total Children Is Unduplicated) 16 16 28.000000 $1432.1000 $51.1500
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 3 1.211111 $60.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 10 7.566667 $378.3400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.046575 $10.7200 $230.1200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 116 123 6.016509 $301.0300 $50.0300
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 0.937501 $23.4400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 16 16 15.650002 $782.5100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 9 9 5.500000 $137.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 4 2.516667 $125.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 4 1.116667 $27.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 5 5 3.625000 $181.2500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 9 9 9.658334 $482.9200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 7 7 4.449999 $111.2500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 5.142857 $128.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 36 41 754.285713 $18857.1500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 348 378 2095.752377 $104787.6700 $50.0000
INTR -T1013 INTERPRETER 14 15 37.059012 $1852.9500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 422 538 3023.024604 $30230.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 44 47 186.434526 $13318.8900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 7 24.511903 $1402.0900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 49 56 176.073809 $12578.7000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 4 25.300000 $1446.1500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.383562 $24.9300 $65.0100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 1.046575 $477.2500 $456.0100
SENS -V5264 EARMOLD 11 12 8.311112 $149.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 63 78 320.214286 $22876.1000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 155.357144 $2156.3600 $13.8800
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Subtotal (Total Children Is Unduplicated) 495 1389 6871.192512 $212909.9100 $30.9900
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Total 1442 6946.292511 $214342.0100 $30.8600
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Number of Children (Unduplicated) With at Least One Authorization 524