Summary Report for FSPSAs Ending During the Report Period Center: 06
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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1174 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 33 35 44.466667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 33 35 44.466667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 17 17 41.142857 $2057.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 19 19 43.142857 $2287.1500 $53.0100
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 7.477778 $373.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 9 4.622222 $231.1100 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 55 57 13.951204 $697.6300 $50.0100
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 31 33 8.238802 $205.9900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 3.033333 $151.6700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.666667 $83.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 3.966667 $99.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 3.033333 $151.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.266667 $106.6700 $25.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 1.666667 $83.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.700000 $17.5000 $25.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.000000 $25.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 29 30 647.142855 $16178.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 260 268 1627.957157 $81397.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 80 83 469.576195 $23478.7900 $50.0000
INTR -T1013 INTERPRETER 23 24 48.666667 $2433.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 389 439 2673.995256 $26739.9500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 29 99.176189 $7085.1600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 6 7 14.411904 $1029.5800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 11.885714 $679.8600 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 1.878571 $107.4600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 32 33 117.642859 $8404.3900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 4 4 8.959524 $640.0700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 4 5.000000 $285.7900 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 14.214286 $812.4900 $57.1600
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 0.500000 $228.0000 $456.0000
SENS -V5264 EARMOLD 8 8 7.755556 $139.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 47 50 207.890477 $14851.6900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 12 12 40.357141 $2883.1300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.357143 $25.5100 $71.4300
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 26.785714 $371.7900 $13.8800
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Subtotal (Total Children Is Unduplicated) 489 1120 6080.782104 $190521.2400 $31.3300
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Total 1174 6168.391628 $192808.3900 $31.2600
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Number of Children (Unduplicated) With at Least One Authorization 517