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 1354 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 -92553 PURE TONE AUDIOMETRY AIR & BONE 50 52 50.411112 $1076.2800 $21.3500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 7.000000 $357.3500 $51.0500
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Subtotal (Total Children Is Unduplicated) 61 64 62.411112 $1688.8800 $27.0600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 478 530 368.102378 $18405.1100 $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
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 65 82 562.026191 $28101.2800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 26 27 139.928569 $9996.5100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 34 36 166.697618 $11908.8800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 5.714286 $326.6300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 48 282.249999 $20163.9300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 1.428571 $19.8300 $13.8800
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Subtotal (Total Children Is Unduplicated) 591 1275 1862.689677 $110849.8200 $59.5100
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Total 1354 1932.389677 $112538.7000 $58.2400
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Number of Children (Unduplicated) With at Least One Authorization 626