Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1088 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 10 13 20.414286 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 10 13 20.414286 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.155556 $3.3200 $21.3600
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.155556 $1.2900 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.155556 $3.9400 $25.3200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.155556 $12.0000 $77.1500
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.155556 $2.8900 $18.5600
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 7 16.742858 $837.1400 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.050000 $2.5500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 9 14 19.570638 $965.2300 $49.3200
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 116 148 143.959970 $7198.0300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 42 42 33.094984 $827.3700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 30 30 23.642779 $1182.1400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 5.044444 $252.2200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 13 13 7.549998 $377.4900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 26 26 16.072220 $803.6100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.966667 $74.1700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 11.714286 $292.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 448 496 2835.265862 $141763.3300 $50.0000
INTR -T1013 INTERPRETER 1 2 9.428572 $471.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 60 68 385.914284 $27569.7100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 69 76 430.152380 $30730.0900 $71.4400
SENS -V5264 EARMOLD 1 1 0.155556 $2.8000 $18.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 127 142 797.361902 $56963.5400 $71.4400
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Subtotal (Total Children Is Unduplicated) 596 1061 4702.323904 $268508.7800 $57.1000
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Total 1088 4742.308828 $269474.0000 $56.8200
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Number of Children (Unduplicated) With at Least One Authorization 605