Summary Report for FSPSAs Initiated During the Report Period Center: 06
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 1335 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 41.013492 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 41.013492 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.145205 $16.7000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 12 12 24.000000 $1200.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 13 13 24.145205 $1216.7000 $50.3900
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.033334 $51.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 11 11 10.055558 $502.7900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.205479 $277.2700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 114 116 4.265234 $213.4700 $50.0500
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 7 7 0.187501 $4.6900 $25.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 16 16 18.361111 $918.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 1.850001 $46.2500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 6.305556 $315.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 1.183334 $29.5900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 14.366665 $718.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 0.883334 $22.0900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 15 16 21.368253 $1068.4100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.866667 $46.6700 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 47.428571 $1185.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 27 28 807.857140 $20196.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 328 346 2236.085740 $111804.1900 $50.0000
INTR -T1013 INTERPRETER 9 12 51.000000 $2550.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 408 503 3078.004007 $30780.0100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 53 190.582142 $13615.2000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 11.171428 $639.0100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 47 52 199.128570 $14225.7300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 9.714286 $555.2700 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.202739 $13.1800 $65.0200
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.145205 $33.1100 $227.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 1.205479 $549.7100 $456.0100
SENS -V5264 EARMOLD 10 10 8.911113 $160.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 80 318.607140 $22761.2800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 3 7.428571 $103.1100 $13.8800
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Subtotal (Total Children Is Unduplicated) 459 1293 7050.404158 $223386.8800 $31.6800
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Total 1335 7115.562855 $224603.5800 $31.5700
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Number of Children (Unduplicated) With at Least One Authorization 484