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: 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 594 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 2.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.000000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 181 181 188.285714 $4422.8300 $23.4900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $133.6500 $44.5500
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Subtotal (Total Children Is Unduplicated) 190 190 197.285714 $4925.6800 $24.9700
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 144 149 132.525396 $6626.2600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 12 12 7.333332 $366.6600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 41 55.889682 $2794.4800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 62 63 49.649208 $2482.4700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 56 57 420.333332 $21016.6900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 4.571429 $45.7100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 3 3 16.714286 $1194.0700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 11 11 49.357143 $2823.2200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 31 31 151.267461 $10806.5400 $71.4400
SENS -V5264 EARMOLD 3 3 3.000000 $54.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 25 144.133333 $10296.8800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 23.990477 $332.9900 $13.8800
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Subtotal (Total Children Is Unduplicated) 253 402 1060.765079 $59299.9600 $55.9000
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Total 594 1260.050793 $64225.6400 $50.9700
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Number of Children (Unduplicated) With at Least One Authorization 400