Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 10-01-17 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 1359 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 14 8.905555 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 8.905555 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 37 18.521616 $898.3100 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $25.3100 $25.3100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.460274 $52.9300 $115.0100
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 4 3.266667 $166.7700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 27 31 16.939041 $864.7400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 7 9 2.111111 $107.7700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.344444 $17.5800 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 32 38 21.926864 $1119.3600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 47 55 33.115676 $1690.5500 $51.0500
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Subtotal (Total Children Is Unduplicated) 109 177 97.685693 $4943.3200 $50.6000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 24 14.260503 $71302.5000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 215 241 549.592065 $27479.6100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 94 105 228.246824 $11412.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 102 114 220.364285 $11018.2100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 216 250 440.025400 $22001.3000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 237 261 1526.715889 $76335.7100 $50.0000
INTR -T1013 INTERPRETER 18 18 141.645238 $7082.2700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 33 220.100004 $15723.9200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 46 57 370.433338 $26463.7500 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.460274 $104.9500 $228.0100
SENS -V5264 EARMOLD 2 2 1.371385 $24.6900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 54 61 398.460325 $28465.9900 $71.4400
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Subtotal (Total Children Is Unduplicated) 361 1168 4112.675530 $297645.2100 $72.3700
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Total 1359 4219.266778 $302588.5300 $71.7200
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Number of Children (Unduplicated) With at Least One Authorization 384