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: 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 866 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 29 29 23.019049 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 23.019049 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 18 24 17.748327 $860.8000 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 6.571429 $182.8800 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 0.597260 $68.6800 $114.9900
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.122222 $6.2400 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 21 22 12.235561 $624.6200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.322222 $67.5000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 38 43 21.018342 $1072.9900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 34 39 21.427777 $1093.8800 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.111111 $4.9500 $44.5500
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Subtotal (Total Children Is Unduplicated) 94 138 81.154251 $3982.5400 $49.0700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 16 10.498174 $52491.0000 $5000.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 20 23 30.819047 $1540.9500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.633333 $40.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 64 74 107.579365 $5378.9700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 57 66 77.218255 $3860.9200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 123 143 138.991260 $6949.5200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 224 250 1311.198414 $65559.9500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 10.123810 $506.1900 $50.0000
INTR -T1013 INTERPRETER 1 1 6.300000 $315.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 24 122.019048 $8717.0400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 38 48 225.566666 $16114.4800 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 2 3 0.597260 $136.1600 $227.9800
SENS -V5264 EARMOLD 2 3 0.597260 $10.7500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 39 44 303.642856 $21692.2600 $71.4400
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Subtotal (Total Children Is Unduplicated) 337 699 2346.784748 $183314.0100 $78.1100
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Total 866 2450.958048 $187296.5500 $76.4200
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Number of Children (Unduplicated) With at Least One Authorization 368