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 660 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 209 209 220.857143 $5187.9300 $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 -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
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Subtotal (Total Children Is Unduplicated) 218 218 229.857143 $5596.1500 $24.3500
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 156 159 129.009525 $6450.4800 $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 47 50 410.404761 $20520.2400 $50.0000
OCCT -97530HM OT SESSION BY OT ASST 15 17 75.500001 $4318.6000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 11 11 50.571429 $3612.8300 $71.4400
SENS -V5264 EARMOLD 4 4 4.000000 $72.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 19 127.500001 $9108.6000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 4.357143 $60.4800 $13.8800
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Subtotal (Total Children Is Unduplicated) 238 442 1014.773808 $54981.6800 $54.1800
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Total 660 1244.630951 $60577.8400 $48.6700
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Number of Children (Unduplicated) With at Least One Authorization 415