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: 10-01-17 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 2876 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 15 15 7.288888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 7.288888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $17.9200 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 314 321 316.934920 $6766.5600 $21.3500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.000000 $230.0000 $115.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 17 17 17.000000 $867.8500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 29 29 28.833333 $1471.9400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 2 2 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 356 379 374.768253 $9801.6200 $26.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 4 4 3.355556 $16778.0000 $5000.0700
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 6.161111 $1417.0500 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 479 531 368.769045 $18438.4400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.588889 $14.7200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 59 62 40.433331 $2021.6600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 105 109 77.084921 $3854.2500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 352 375 215.846035 $10792.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.588889 $14.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.011111 $0.2800 $24.9800
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 698 868 5717.592876 $285879.5200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 125 140 629.499999 $44971.4900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 161 173 743.319045 $53102.7000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 7.142857 $408.2900 $57.1600
SENS -V5264 EARMOLD 1 1 1.000000 $18.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 178 204 985.071429 $70373.3900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 7.499999 $104.1000 $13.8800
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Subtotal (Total Children Is Unduplicated) 926 2482 8803.965093 $508188.9200 $57.7200
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Total 2876 9186.022234 $517990.5300 $56.3900
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Number of Children (Unduplicated) With at Least One Authorization 973