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: 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 629 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 0.300000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.300000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 251 253 261.857143 $6151.0200 $23.4900
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.122222 $6.2400 $51.0400
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Subtotal (Total Children Is Unduplicated) 253 255 262.979365 $6208.3100 $23.6100
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 140 140 119.288885 $5964.4300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 13 7.755556 $387.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 49 53.333334 $2666.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 74 74 40.288885 $2014.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 37 41 276.426983 $13821.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 17.142857 $171.4300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 6.000000 $428.6400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 32.857143 $1879.4300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 23 23 110.139683 $7868.3700 $71.4400
SENS -V5264 EARMOLD 3 3 3.000000 $54.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 14 14 73.351985 $5240.2700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 66.780952 $926.9200 $13.8800
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Subtotal (Total Children Is Unduplicated) 223 373 807.366263 $41653.6900 $51.5900
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Total 629 1070.645628 $47862.0000 $44.7000
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Number of Children (Unduplicated) With at Least One Authorization 429