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: 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 491 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 2 2 0.988889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 0.988889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 101 101 107.279365 $2519.9900 $23.4900
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 8.428571 $412.5000 $48.9400
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Subtotal (Total Children Is Unduplicated) 104 105 117.707936 $3034.5900 $25.7800
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 136 140 95.547623 $4777.4000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 6 6 2.200000 $110.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 40 40 25.800000 $1290.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 56 57 29.566666 $1478.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 47 48 263.268249 $13163.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 11 11 47.452383 $3389.9900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 12 12 40.214285 $2300.2600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 38 38 153.713491 $10981.3000 $71.4400
SENS -V5264 EARMOLD 2 2 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 27 137.678572 $9835.7600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 29.714285 $412.4300 $13.8800
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Subtotal (Total Children Is Unduplicated) 249 384 828.155554 $48004.9000 $57.9700
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Total 491 946.852379 $51039.4900 $53.9000
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Number of Children (Unduplicated) With at Least One Authorization 325