Summary Report for FSPSAs Ending During the Report Period Center: 10
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2766 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 10 10 5.611111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 10 5.611111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $14.9300 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 263 263 100.638893 $1932.2700 $19.2000
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.416667 $15.9900 $38.3700
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 22 23 17.377778 $887.1400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 8 4.966666 $253.5400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 35 39 31.005557 $1582.8400 $51.0500
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Subtotal (Total Children Is Unduplicated) 311 335 155.405561 $4686.7100 $30.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.266667 $1333.5000 $5000.6200
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.900000 $215.2800 $239.2000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 456 520 198.239691 $9912.0300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 73 78 43.611109 $2180.5500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 122 128 78.174994 $3908.7200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 287 306 183.067459 $9153.3700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 696 857 5345.732947 $267286.6300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 129 140 599.733330 $42844.9700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 167 186 702.444047 $50182.5900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 184 204 929.290479 $66388.5100 $71.4400
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Subtotal (Total Children Is Unduplicated) 894 2421 8081.460723 $453406.1300 $56.1000
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Total 2766 8242.477395 $458092.8500 $55.5800
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Number of Children (Unduplicated) With at Least One Authorization 929