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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1680 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 37 37 61.806350 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 37 37 61.806350 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.333333 $383.3300 $115.0000
EXIT -EXIT EXIT ASSESSMENT 39 41 91.571429 $4578.5700 $50.0000
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Subtotal (Total Children Is Unduplicated) 41 43 94.904762 $4961.9000 $52.2800
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 3.788889 $189.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 7 5.333333 $266.6700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 112 113 24.922527 $1246.2400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 8 2.016668 $50.4200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 7 6.283334 $314.1700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 4 4 2.350000 $58.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.761112 $138.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.083333 $2.0800 $24.9900
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 3 1.227778 $61.3900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 4.352778 $217.6400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.266667 $56.6700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 90 96 2053.714302 $51342.8200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 473 510 3114.738145 $155736.9000 $50.0000
INTR -T1013 INTERPRETER 20 25 142.000000 $7100.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 529 618 3692.686571 $36926.8600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 57 211.195237 $15087.7800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 14 14 43.588095 $2493.2400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 33 38 134.857144 $9634.1900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 2 0.333333 $19.0500 $57.1500
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 8 9 5.311110 $95.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 56 65 231.785721 $16558.7100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 0.928571 $12.8900 $13.8800
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Subtotal (Total Children Is Unduplicated) 650 1600 9691.524648 $298816.5500 $30.8300
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Total 1680 9848.235760 $303778.4500 $30.8500
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Number of Children (Unduplicated) With at Least One Authorization 691