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 652 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
EXIT -EXIT EXIT ASSESSMENT 17 17 41.142857 $2057.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 17 17 41.142857 $2057.1500 $50.0000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.000000 $50.0000 $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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 11 11 66.228571 $3311.4300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 16.571429 $828.5700 $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 3 3 9.428571 $673.5800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.571429 $183.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 16.928572 $1209.3700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.285714 $130.6500 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.500000 $228.0000 $456.0000
SENS -V5264 EARMOLD 1 1 0.500000 $9.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 9.571429 $683.7900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.428571 $459.2600 $71.4400
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Subtotal (Total Children Is Unduplicated) 419 600 2896.205105 $38562.8700 $13.3100
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Total 652 2981.814629 $40620.0100 $13.6200
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Number of Children (Unduplicated) With at Least One Authorization 449