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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 875 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 36 36 37.373019 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 36 36 37.373019 $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 7 7 14.000000 $700.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 8 8 15.000000 $815.0000 $54.3300
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.355556 $17.7800 $50.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 82 84 17.954651 $897.8200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 1.750000 $87.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 75 75 25.000804 $625.0400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 6 4.216665 $210.8300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 0.800000 $40.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 7 7 7.400000 $185.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4 4 5.666666 $283.3300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.333333 $16.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 4.183333 $104.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.933333 $96.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 2.783333 $139.1700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 0.800000 $40.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.750000 $43.7500 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 8 50.000000 $2500.0000 $50.0000
INTR -T1013 INTERPRETER 39 41 141.357143 $7067.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 493 576 3398.076193 $33980.7500 $10.0000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 0.928571 $53.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 4 4 26.714285 $1908.4700 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.000000 $130.0000 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 1 1 0.355556 $6.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 8.857142 $632.7600 $71.4400
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Subtotal (Total Children Is Unduplicated) 537 831 3704.216564 $49295.4700 $13.3100
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Total 875 3756.589583 $50110.4700 $13.3400
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Number of Children (Unduplicated) With at Least One Authorization 571