Summary Report for FSPSAs Initiated During the Report Period Center: 10
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 2023 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
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 235 235 249.714286 $5865.7900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 34 36 36.000000 $1837.8000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 5.411111 $276.2400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 4 4 4.000000 $204.2000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 47 49 59.426984 $2647.4700 $44.5500
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Subtotal (Total Children Is Unduplicated) 312 337 361.552381 $11150.6100 $30.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 156 160 129.676192 $6483.8200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 23 15.433331 $771.6600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 79 141.984923 $7099.2600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 75 77 54.490472 $2724.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.522222 $13.0600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 583 639 4776.096037 $238804.7700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 19.666667 $983.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 34 35 175.428570 $12532.6200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 167 177 1015.133338 $58065.6000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 231 239 1081.719047 $77278.0300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 33.857143 $1935.2800 $57.1600
SENS -V5264 EARMOLD 4 4 4.000000 $72.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 215 225 1357.130162 $96953.3200 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 0.285714 $20.4100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 10 11 69.785715 $968.6300 $13.8800
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Subtotal (Total Children Is Unduplicated) 896 1686 8878.209533 $514936.2700 $58.0000
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Total 2023 9239.761914 $526086.8800 $56.9400
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Number of Children (Unduplicated) With at Least One Authorization 925