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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1938 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 6 6 8.221429 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 9.714286 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 7 7 17.935715 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 25 31 41.096825 $1993.1900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 3.127778 $176.6900 $56.4900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 8 4.266667 $101.1200 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 7.988888 $677.7700 $84.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 4.616666 $207.7500 $45.0000
EXIT -EXIT EXIT ASSESSMENT 31 34 48.829984 $2441.5000 $50.0000
SCREEN-T1023 SCREENING 11 11 4.166666 $208.3300 $50.0000
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Subtotal (Total Children Is Unduplicated) 87 101 115.093474 $5828.7500 $50.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 22 22.611113 $113056.5000 $5000.0400
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.177778 $8.8900 $50.0100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 0.850000 $60.8700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.072222 $246.6100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 86 96 78.758332 $3937.9100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 4 4 4.250000 $212.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 4 5.500000 $137.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 48 52 53.327778 $2666.3900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 72 76 51.516665 $2575.8300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 3 1.966667 $98.3400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.758333 $18.9600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 68 70 46.663893 $2333.2200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 0.211111 $10.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 132 138 78.288885 $3914.4300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 3.666667 $183.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 2.688889 $67.2200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 341 381 1875.914288 $93795.7200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 9 9 41.866665 $2093.3300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 456 842 2703.902381 $27039.0300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 43 238.644444 $17048.7800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.000000 $142.8800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 4.387301 $250.9500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.571429 $547.4800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 29 29 122.550792 $8755.0200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 3.866667 $276.2400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.266667 $15.2400 $57.1700
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.533333 $395.3000 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.144444 $65.8500 $455.8600
SENS -V5264 EARMOLD 1 1 0.144444 $2.6000 $17.9900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 29 30 125.267460 $8949.1000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 14.457143 $1032.8200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 47.066667 $653.2900 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.571429 $21.1400 $37.0000
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Subtotal (Total Children Is Unduplicated) 474 1830 5548.463887 $290613.8100 $52.3800
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Total 1938 5681.493076 $296442.5600 $52.1800
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Number of Children (Unduplicated) With at Least One Authorization 484