Summary Report for FSPSAs Initiated During the Report Period Center: 06
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: 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 1069 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 40 40 52.901588 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 40 40 52.901588 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
EXIT -EXIT EXIT ASSESSMENT 22 22 51.142857 $2557.1500 $50.0000
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Subtotal (Total Children Is Unduplicated) 22 22 51.142857 $2557.1500 $50.0000
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 4.133333 $206.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 6.277778 $313.8900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 48 49 9.523425 $476.2400 $50.0100
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 2 2 8.576985 $428.8500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 31 32 7.693065 $192.3500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.533333 $26.6700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 3.066667 $153.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 3.766667 $94.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 1.133333 $56.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.300000 $107.5000 $25.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 1 1 3.066667 $153.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.533333 $13.3300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 16 16 382.571427 $9564.2900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 273 287 1906.461886 $95323.1700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 28 29 187.633337 $9381.6600 $50.0000
INTR -T1013 INTERPRETER 25 28 102.714287 $5135.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 353 403 2711.780927 $27117.8200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 18 68.116667 $4866.2600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 5 21.785715 $1556.3700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 30.000001 $1716.0000 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 0.928571 $53.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 29 31 147.978572 $10571.6000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 5 5 27.285715 $1949.2900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 8 9 30.285714 $1731.1300 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 2.320548 $150.8400 $65.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 5 5 5.877778 $105.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 46 49 190.678571 $13622.1000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 17.928572 $1280.8200 $71.4400
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Subtotal (Total Children Is Unduplicated) 406 1007 5890.952874 $187720.9600 $31.8700
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Total 1069 5994.997319 $190278.1000 $31.7400
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Number of Children (Unduplicated) With at Least One Authorization 449