Summary Report for FSPSAs Initiated During the Report Period Center: 52
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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 954 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 2 2 1.611111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.611111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.833333 $16.6500 $9.0800
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.035616 $4.0900 $114.9500
EXIT -EXIT EXIT ASSESSMENT 2 2 2.000000 $100.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 12 12 12.133333 $619.4100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 6 6.000000 $306.3000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 8 7.166667 $365.8600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
SCREEN-T1023 SCREENING 29 29 30.833333 $1541.6700 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 5.000000 $255.2500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $48.9400 $48.9400
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Subtotal (Total Children Is Unduplicated) 64 71 72.002282 $3564.4600 $49.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 4.550793 $22754.0000 $5000.0100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 5.966667 $427.2800 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 8 10 32.678571 $1633.9300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 154 186 451.954766 $22597.7600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 97 120 292.666672 $14633.3600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 50 119.100000 $5955.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 97 101 240.833337 $12041.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 195 200 1146.659936 $57333.0300 $50.0000
INTR -T1013 INTERPRETER 2 2 4.071428 $203.5800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 60 281.530957 $20112.5500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 25 28 153.719052 $8792.7300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 27 28 131.804763 $9416.1100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 3 12.333333 $704.9700 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 3 3 6.111111 $110.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 76 79 370.019051 $26434.1600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 19.207143 $266.6000 $13.8800
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Subtotal (Total Children Is Unduplicated) 316 881 3279.340913 $203773.0600 $62.1400
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Total 954 3352.954306 $207337.5200 $61.8400
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Number of Children (Unduplicated) With at Least One Authorization 334