Summary Report for FSPSAs Initiated During the Report Period Center: 10
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: 10-01-16 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 1019 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 9 10 3.933333 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 9 10 3.933333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 24 24 22.672222 $435.3100 $19.2000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $46.8000 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $119.6000 $119.6000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 6.288889 $321.0500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 2 3 3.000000 $153.1500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 6 6.000000 $306.3000 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 37 42 39.961111 $1382.2000 $34.5900
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 390 415 198.468247 $9923.3800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 51 54 32.072222 $1603.6100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 86 90 55.499994 $2774.9700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 262 268 148.815080 $7440.7600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 37 45 245.165079 $12258.2700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 20 103.571428 $7399.1300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 32 33 167.857141 $11991.7400 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $237.1200 $237.1200
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 40 185.080953 $13222.1900 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 478 967 1138.530144 $66869.1700 $58.7300
-------------------------------------------------------------------------------------------------------------------------------------
Total 1019 1182.424588 $68251.3700 $57.7200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 498