Summary Report for FSPSAs Initiated During the Report Period Center: 03
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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1282 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 40 41 32.953969 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 40 41 32.953969 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 26 16.365981 $793.7500 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 4.142857 $115.3000 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.063014 $7.2500 $114.9700
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 25 12.489575 $637.6000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 43 46 25.988575 $1326.7200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 40 46 24.221917 $1236.5200 $51.0500
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Subtotal (Total Children Is Unduplicated) 107 146 83.271919 $4117.1400 $49.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 27 18.182649 $90914.0000 $5000.0400
CONIF -CONIF CONSULT, ITDS FACE TO FACE 197 242 305.603177 $15280.1800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 92 111 109.888886 $5494.4300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 79 92 133.015878 $6650.8200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 179 206 202.161900 $10108.0800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 232 282 1291.214293 $64560.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 27 130.219049 $9302.8500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 49 58 265.080957 $18937.3900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 8.866667 $506.8200 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.063014 $14.3600 $227.9500
SENS -V5264 EARMOLD 1 1 0.063014 $1.1300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 41 46 220.800005 $15773.9200 $71.4400
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Subtotal (Total Children Is Unduplicated) 361 1095 2685.159489 $237544.6900 $88.4700
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Total 1282 2801.385377 $241661.8300 $86.2700
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Number of Children (Unduplicated) With at Least One Authorization 398