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 840 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
EXIT -EXIT EXIT ASSESSMENT 12 12 24.000000 $1200.0000 $50.0000
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) 14 14 26.000000 $1266.0500 $48.6900
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.011111 $50.5600 $50.0000
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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 12 58.419045 $2920.9600 $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 5 5 16.142857 $1153.2500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 12 12 44.019047 $3144.7200 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.183562 $11.9300 $65.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 12 13 61.464286 $4391.0100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 129.642859 $1799.4400 $13.8800
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Subtotal (Total Children Is Unduplicated) 448 789 3420.437062 $47728.7200 $13.9500
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Total 840 3493.537061 $48994.7700 $14.0200
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Number of Children (Unduplicated) With at Least One Authorization 479