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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1528 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 43 45 53.277780 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 43 45 53.277780 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 19 19 38.000000 $1900.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 20 20 39.000000 $2015.0000 $51.6700
EI Services, Class # 03
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.177778 $58.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 12 13 10.722222 $536.1100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 4.000000 $920.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 78 84 19.952671 $997.7400 $50.0100
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 1.011112 $50.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 61 63 19.911441 $497.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 6.233334 $311.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.366667 $34.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 2.950000 $147.5000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 1.133333 $56.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.433334 $71.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 1.150000 $57.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.366667 $34.1700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 34 36 749.571426 $18739.2800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 432 471 2950.457158 $147522.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 11 12 64.000000 $3200.0100 $50.0000
INTR -T1013 INTERPRETER 17 18 144.499999 $7225.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 495 565 3562.010333 $35620.1100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 16 42.323810 $3023.6100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 6 6 21.495238 $1535.6200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 9 9 39.871428 $2280.6500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 6 25.928572 $1483.1100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 30 33 104.428570 $7460.3800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 10 12 29.152382 $2082.6500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 4 6 20.500000 $1171.7700 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 3.214286 $183.7300 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.197260 $77.8200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 4.000000 $1824.0000 $456.0000
SENS -V5264 EARMOLD 13 14 11.066667 $199.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 57 238.959526 $17071.2600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 11 11 35.000000 $2500.3900 $71.4400
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Subtotal (Total Children Is Unduplicated) 582 1463 8122.085214 $257317.8900 $31.6800
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Total 1528 8214.362994 $259332.8900 $31.5700
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Number of Children (Unduplicated) With at Least One Authorization 625