Summary Report for FSPSAs Initiated During the Report Period Center: 10
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 3056 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 5 5 3.588889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 3.588889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 325 327 325.466667 $6948.7100 $21.3500
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 3.000000 $345.0000 $115.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 21 23 22.533333 $1150.3300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 9 9 8.522222 $435.0600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 29 33 32.833333 $1676.1400 $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) 369 398 395.355555 $10696.2900 $27.0500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 3.000000 $15000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 549 582 368.119829 $18405.9300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 62 63 41.055558 $2052.7900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 109 112 79.899998 $3994.9900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 409 417 259.582531 $12979.0800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 0.011111 $0.2800 $24.9800
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 724 902 6498.059544 $324902.8700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 151 164 848.035716 $60583.6700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 182 192 834.007924 $59581.5500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.785714 $44.9100 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 192 213 1101.178571 $78668.1600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 11.642857 $161.6000 $13.8800
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Subtotal (Total Children Is Unduplicated) 943 2653 10046.379353 $576605.8200 $57.3900
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Total 3056 10445.323797 $587302.1100 $56.2300
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Number of Children (Unduplicated) With at Least One Authorization 961