Summary Report for FSPSAs Initiated During the Report Period Center: 54
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: 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 1685 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 7 7 22.880953 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.857143 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 8 8 28.738096 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 27 29 49.124602 $2382.5400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.000000 $225.9600 $56.4900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 3.250001 $77.0300 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 13 13.072222 $1109.0500 $84.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.000000 $44.8000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 6 6 5.433333 $244.5000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 19 19 32.011112 $1600.5600 $50.0000
SCREEN-T1023 SCREENING 6 6 3.866667 $193.3400 $50.0000
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.944444 $47.2200 $50.0000
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Subtotal (Total Children Is Unduplicated) 78 86 113.702381 $5924.9800 $52.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 17 18.211111 $91055.5000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 5 10.500000 $2415.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 93 105 88.297221 $4414.8600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 5 5 4.666667 $233.3400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 6.500000 $162.5000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 49 61 54.244443 $2712.2200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 4 5 8.394444 $419.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 70 70 65.135716 $3256.8000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 6 7 3.411110 $170.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.988889 $24.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 48 39.028569 $1951.4200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 3 3 0.994444 $49.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 121 123 116.621428 $5831.0800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 8 8 5.522222 $276.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.844444 $21.1100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 0.238889 $11.9500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 242 253 1516.375394 $75818.7900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 10 10 37.165080 $1858.2500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 378 718 2497.935703 $24979.3500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 36 37 193.928570 $13854.2500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 15.776190 $1127.0500 $71.4400
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 14.714286 $1051.1800 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 16.428571 $1173.6600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 25 25 115.238095 $8232.6000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 4 32.158730 $2297.4200 $71.4400
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.533333 $395.3000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 4.761110 $340.1300 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.866667 $395.2200 $456.0200
SENS -V5264 EARMOLD 1 1 0.866667 $15.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 50 51 254.101585 $18153.0200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 15.257143 $1089.9700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 5.922222 $423.0800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 39.090475 $542.5800 $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) 402 1591 5190.290847 $264775.1500 $51.0100
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Total 1685 5332.731324 $270700.1300 $50.7600
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Number of Children (Unduplicated) With at Least One Authorization 416