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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 884 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 46 47 23.755552 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 46 47 23.755552 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 10 11 9.391792 $455.5100 $48.5000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $27.8300 $27.8300
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.306850 $35.2800 $114.9800
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 8.108970 $413.9600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 30 32 15.932114 $813.3300 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.238889 $12.2000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.011111 $51.6200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 24 27 13.827779 $705.9100 $51.0500
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Subtotal (Total Children Is Unduplicated) 76 97 49.817505 $2515.6300 $50.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 10 15.784399 $78922.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 12 14 19.455555 $972.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 63 70 83.577778 $4178.8900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 1.255556 $62.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 41 43 46.233333 $2311.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 132 141 142.812704 $7140.6600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 5 5 3.666666 $183.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 295 331 1328.355553 $66417.7400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 15.752381 $787.6200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 32 34 111.757141 $7983.9400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 38 39 201.266666 $14378.5000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 6.142857 $438.8500 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 0.306850 $69.9500 $227.9600
SENS -V5264 EARMOLD 3 3 0.471233 $8.4800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 33 38 145.619048 $10403.0200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.033333 $42.1000 $13.8800
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Subtotal (Total Children Is Unduplicated) 418 740 2126.491053 $194532.3000 $91.4800
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Total 884 2200.064110 $197047.9400 $89.5600
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Number of Children (Unduplicated) With at Least One Authorization 463