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: 10-01-21 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 1467 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 42 42 41.252381 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 41.252381 $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 13 13 26.000000 $1300.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 15 15 28.000000 $1530.0000 $54.6400
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 17 17 20.211111 $1010.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 80 84 21.002671 $1050.2400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 1.011112 $50.5600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 62 64 20.947552 $523.7100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 4 4 4.933333 $246.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 8.033334 $200.8400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 5 6.299999 $315.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.766667 $69.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 2.483333 $124.1700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.366667 $84.1700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 15 338.999998 $8475.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 463 490 3041.223802 $152061.3400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 16 19 117.857142 $5892.8700 $50.0000
INTR -T1013 INTERPRETER 13 13 70.499999 $3525.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 503 550 3495.276982 $34952.8000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 19 104.373809 $7456.4500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 3.142857 $224.5200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 6 18.071430 $1033.6800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 5 13.785715 $788.5500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 25 27 150.928573 $10782.3200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 5 8 21.142858 $1510.4500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 6 26.500000 $1514.7300 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 2 3.357143 $191.9000 $57.1600
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 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 13 13 12.866667 $231.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 34 35 136.607146 $9759.2000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 6 21.357143 $1525.7500 $71.4400
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Subtotal (Total Children Is Unduplicated) 584 1410 7672.047043 $245085.2100 $31.9500
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Total 1467 7741.299424 $246615.2100 $31.8600
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Number of Children (Unduplicated) With at Least One Authorization 628