Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1496 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 14 15 6.022221 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 15 6.022221 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 37 16.219332 $786.6500 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.477778 $12.0900 $25.3100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.153425 $17.6400 $114.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 27 33 17.603807 $898.6800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 6 1.022222 $52.1800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 24 31 20.990716 $1071.5800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 9.428571 $481.3300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 63 70 39.737825 $2028.6300 $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) 119 184 109.633676 $5552.9800 $50.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 25 12.924886 $64624.5000 $5000.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 215 251 473.761902 $23688.0800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 115 130 212.043650 $10602.1900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 108 125 185.949206 $9297.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 238 269 413.583340 $20679.2000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 248 281 1280.026987 $64001.4000 $50.0000
INTR -T1013 INTERPRETER 19 22 116.367463 $5818.3800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 38 239.528573 $17111.8900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 3.066667 $175.4200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 46 61 286.528569 $20469.5900 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.153425 $34.9800 $227.9600
SENS -V5264 EARMOLD 3 3 0.680974 $12.2600 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 78 87 530.176192 $37875.7800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 25.428571 $352.9500 $13.8800
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Subtotal (Total Children Is Unduplicated) 405 1297 3780.220405 $274744.0600 $72.6800
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Total 1496 3895.876302 $280297.0500 $71.9500
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Number of Children (Unduplicated) With at Least One Authorization 427