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 1281 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 -92553 PURE TONE AUDIOMETRY AIR & BONE 41 41 17.144444 $329.1700 $19.2000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 4.711111 $240.5000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 6.522222 $332.9600 $51.0500
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Subtotal (Total Children Is Unduplicated) 55 57 28.377777 $902.6300 $31.8100
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 53 64 354.796829 $17739.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 27 120.928570 $8639.1500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 32 37 175.821427 $12560.6900 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 48 52 302.647614 $21621.1500 $71.4400
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Subtotal (Total Children Is Unduplicated) 564 1214 1458.454360 $87264.2900 $59.8300
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Total 1281 1492.443248 $88166.9200 $59.0800
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Number of Children (Unduplicated) With at Least One Authorization 586