Summary Report for FSPSAs Initiated During the Report Period Center: 10
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 375 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
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 99 99 99.000000 $2325.5100 $23.4900
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $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) 101 102 102.000000 $2476.5500 $24.2800
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 110 112 98.822224 $4941.1200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.966666 $148.3300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 27 27 22.133334 $1106.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 25 25 15.700001 $785.0100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 33 35 277.228573 $13861.4400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 23.212699 $1658.3200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 8 8 61.071430 $3493.2800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 29 31 139.265876 $9949.1300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 25 135.853969 $9705.4000 $71.4400
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Subtotal (Total Children Is Unduplicated) 203 273 777.254772 $45878.6900 $59.0300
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Total 375 879.254772 $48355.2400 $55.0000
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Number of Children (Unduplicated) With at Least One Authorization 288