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: 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 1022 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 55 56 36.299770 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 55 56 36.299770 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 15 23 15.400610 $746.9400 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.295890 $34.0300 $115.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 25 12.355557 $630.7600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 28 35 18.145664 $926.3400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 37 46 24.182423 $1234.5300 $51.0500
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Subtotal (Total Children Is Unduplicated) 84 131 71.380144 $3600.4300 $50.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 14 9.517275 $47586.5000 $5000.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 127 143 209.665073 $10483.2300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 82 93 104.322219 $5216.1000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 49 55 71.387305 $3569.3900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 144 161 172.016672 $8600.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 227 257 1357.292057 $67864.5800 $50.0000
INTR -T1013 INTERPRETER 1 1 9.000000 $450.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 25 28 152.634920 $10904.2100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 30 39 180.423808 $12889.4700 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.608219 $138.6700 $227.9900
SENS -V5264 EARMOLD 2 2 0.608219 $10.9500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 40 201.252380 $14377.4600 $71.4400
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Subtotal (Total Children Is Unduplicated) 341 835 2468.728147 $182091.4000 $73.7600
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Total 1022 2576.408061 $185691.8300 $72.0700
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Number of Children (Unduplicated) With at Least One Authorization 397