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 698 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 86 86 86.000000 $2020.1400 $23.4900
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 2.477778 $121.2600 $48.9400
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Subtotal (Total Children Is Unduplicated) 92 93 92.477778 $2345.6000 $25.3600
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $690.0000 $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 55 56 389.363488 $19468.1900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 20 84.428571 $6031.5600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 11 11 77.101588 $4410.2100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 51 54 197.642862 $14119.6100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.928571 $281.7200 $57.1600
SENS -V5264 EARMOLD 2 2 1.566667 $28.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 40 216.071428 $15436.1400 $71.4400
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Subtotal (Total Children Is Unduplicated) 334 604 1270.438073 $75282.2500 $59.2600
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Total 698 1363.660295 $77627.8600 $56.9300
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Number of Children (Unduplicated) With at Least One Authorization 391