Summary Report for FSPSAs Ending During the Report Period Center: 54
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: 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 1396 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 3 3 8.309523 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 6.228571 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 14.538094 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 35 29.388886 $1425.3500 $48.5000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.166667 $14.1400 $84.8600
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.044444 $0.9900 $22.3800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.022222 $1.0000 $44.9600
EXIT -EXIT EXIT ASSESSMENT 47 48 74.472364 $3723.6200 $50.0000
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Subtotal (Total Children Is Unduplicated) 73 86 104.094583 $5165.1000 $49.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 15 22.022223 $110111.5000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.120548 $6.0300 $49.9800
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.044444 $10.2100 $229.7700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 83 90 69.526571 $3476.3300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 1.172223 $29.3100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 76 93 120.889686 $6044.5100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 78 71.994444 $3599.7200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 47 60.849209 $3042.4700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 98 101 73.755554 $3687.7700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.544444 $13.6100 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 2 2 18.304762 $1342.1000 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 21 129.646825 $6482.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 453 841 2721.389668 $27213.9000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 5.611111 $400.8600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 2 2 2.088889 $149.2300 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.022222 $10.1200 $455.5500
SENS -V5264 EARMOLD 1 1 0.088889 $1.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 5 18.076190 $1291.3600 $71.4400
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Subtotal (Total Children Is Unduplicated) 460 1305 3316.147902 $166912.9700 $50.3300
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Total 1396 3434.780579 $172078.0700 $50.1000
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Number of Children (Unduplicated) With at Least One Authorization 465