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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 916 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 54 55 29.134389 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 54 55 29.134389 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 29 22.101901 $1071.9400 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $55.6600 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.158904 $18.2700 $115.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 19 9.378744 $478.7800 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 31 34 21.319459 $1088.3500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 36 38 21.444445 $1094.7400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.377778 $16.8300 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 85 126 78.781231 $3926.6700 $49.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 18 12.413013 $62065.0000 $4999.9900
CONIF -CONIF CONSULT, ITDS FACE TO FACE 85 86 74.455560 $3722.8000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 74 81 98.461113 $4923.0700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 61 67 86.336513 $4316.8500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 138 140 120.115083 $6005.7800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 2 2 0.800000 $40.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 224 236 1163.750790 $58187.5600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 22.266667 $1113.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 19 95.199999 $6801.1000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 35 39 224.119047 $16011.0800 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.350685 $79.9600 $228.0100
SENS -V5264 EARMOLD 2 2 0.350685 $6.3100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 40 227.998413 $16288.2000 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 335 735 2126.617568 $179561.0300 $84.4400
-------------------------------------------------------------------------------------------------------------------------------------
Total 916 2234.533188 $183487.7000 $82.1100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 392