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: 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 636 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 27 28 14.211114 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 27 28 14.211114 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 7.878615 $382.1100 $48.5000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.169863 $19.5400 $115.0300
OCTH -97167 OT EVAL HIGH COMPLEXITY 16 18 15.853382 $809.3200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 22 23 13.974811 $713.4200 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.277778 $14.1800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 21 23 12.888889 $657.9800 $51.0500
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Subtotal (Total Children Is Unduplicated) 58 80 54.043338 $2749.7000 $50.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 9 5.511949 $27560.0000 $5000.0500
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 10 7.244445 $362.2300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.822222 $91.1100 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 55 63 93.542854 $4677.1300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 3 3 6.711110 $335.5500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 52 40.966668 $2048.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 95 104 109.550797 $5477.5600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 5 7 5.711110 $285.5500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 176 186 850.550790 $42527.5400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 10 11 72.619047 $3630.9500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 18 101.152381 $7226.3100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 25 28 124.800000 $8915.7000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 7.142857 $510.2900 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.169863 $38.7400 $228.0500
SENS -V5264 EARMOLD 1 1 0.509589 $9.1700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 29 31 163.785714 $11700.8500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 5.666666 $78.6500 $13.8800
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Subtotal (Total Children Is Unduplicated) 268 528 1597.458062 $115475.6600 $72.2900
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Total 636 1665.712514 $118225.3600 $70.9800
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Number of Children (Unduplicated) With at Least One Authorization 300