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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1078 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 27.559522 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 55 56 27.559522 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 19 12.616668 $611.9200 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.843835 $97.0400 $115.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 24 25 11.144446 $568.9300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.322222 $16.4500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 32 38 19.137596 $976.9800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 31 32 15.850532 $809.1600 $51.0500
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Subtotal (Total Children Is Unduplicated) 90 118 59.915299 $3080.4700 $51.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 16 10.683334 $53417.0000 $5000.0300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 158 170 194.026995 $9701.4100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 83 94 97.961114 $4898.0700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 63 68 69.138095 $3456.9000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 163 178 160.157939 $8007.9100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 232 255 1159.114276 $57955.7700 $50.0000
INTR -T1013 INTERPRETER 1 1 3.285714 $164.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 31 149.158729 $10655.9000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 38 49 202.142854 $14441.0900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.266667 $129.5600 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 0.843835 $192.3900 $227.9900
SENS -V5264 EARMOLD 3 3 0.843835 $15.1900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 35 173.627776 $12403.9600 $71.4400
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Subtotal (Total Children Is Unduplicated) 347 904 2223.251163 $175439.4300 $78.9100
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Total 1078 2310.725984 $178519.9000 $77.2600
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Number of Children (Unduplicated) With at Least One Authorization 401