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: 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 1939 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 1 1 0.744444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.744444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 290 293 296.714286 $6969.8200 $23.4900
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 5.277778 $269.4300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.477778 $75.4400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 7 7 6.466667 $316.4800 $48.9400
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Subtotal (Total Children Is Unduplicated) 308 314 315.936509 $7937.4700 $25.1200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.388889 $1944.5000 $5000.1400
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 4.000000 $920.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 203 211 165.803164 $8290.1100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 10.855556 $542.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 84 84 46.463482 $2323.1300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 106 108 73.212696 $3660.6200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 621 671 4958.712683 $247935.7100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 85 396.714285 $28341.2600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 61 64 270.315878 $15462.0600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 201 207 795.857153 $56856.0700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 13.000000 $743.0800 $57.1600
SENS -V5264 EARMOLD 14 14 13.566667 $244.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 147 155 745.178574 $53235.5700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 4.857143 $277.8300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 6.142857 $85.2600 $13.8800
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Subtotal (Total Children Is Unduplicated) 848 1624 7505.069027 $420862.1800 $56.0800
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Total 1939 7821.749980 $428799.6500 $54.8200
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Number of Children (Unduplicated) With at Least One Authorization 878