Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1287 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 67 73 45.613242 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 67 73 45.613242 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 24 14.235236 $690.4100 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 15.714286 $437.3300 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 1.326027 $152.4900 $115.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 26 29 15.551068 $793.8900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 47 55 28.603120 $1460.1900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 38 45 25.935843 $1324.0200 $51.0500
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Subtotal (Total Children Is Unduplicated) 114 164 101.365580 $4858.3300 $47.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 19 20 14.395889 $71979.0000 $4999.9700
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.087671 $250.1700 $230.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 202 213 271.525402 $13576.3000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 91 104 119.634130 $5981.7300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 85 95 118.955557 $5947.7900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 202 221 226.795242 $11339.7800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 233 249 1216.099989 $60805.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 33 204.142857 $14583.9600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 46 57 266.776190 $19058.5100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 3.466667 $198.1600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 8 8 1.632876 $372.3000 $228.0000
SENS -V5264 EARMOLD 7 7 1.413698 $25.4500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 40 164.190471 $11729.8100 $71.4400
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Subtotal (Total Children Is Unduplicated) 373 1050 2610.116639 $215847.9400 $82.7000
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Total 1287 2757.095461 $220706.2700 $80.0500
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Number of Children (Unduplicated) With at Least One Authorization 440