Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1034 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 11 11 10.020635 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 10.020635 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.183333 $8.2500 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.183333 $21.0800 $114.9800
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 10 18.794443 $939.7300 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 13 14 21.161109 $1071.1600 $50.6200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 114 136 111.830059 $5591.5400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 52 55 26.689361 $667.2400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 34 36 24.029231 $1201.4600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 2.650000 $132.5000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 19 20 8.281974 $414.1000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 25 26 26.128568 $1306.4300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.000000 $50.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 4 10.142857 $253.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 464 489 2903.304757 $145165.3800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 42 281.999998 $20146.0800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 5.285714 $302.3400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 70 74 442.710237 $31627.2500 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.183333 $41.7900 $227.9600
SENS -V5264 EARMOLD 1 1 0.183333 $3.3000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 107 115 707.000000 $50508.1000 $71.4400
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Subtotal (Total Children Is Unduplicated) 593 1009 4553.419422 $257436.0700 $56.5400
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Total 1034 4584.601166 $258507.2200 $56.3900
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Number of Children (Unduplicated) With at Least One Authorization 601