Summary Report for FSPSAs Ending During the Report Period Center: 10
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 2048 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 2 2 1.188889 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2 2 1.188889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 310 310 324.142857 $7614.1200 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $27.7400 $13.8700
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 30 30 30.000000 $1531.5000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 10.100000 $515.6100 $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 4 4 4.000000 $204.2000 $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 35 35 33.800000 $1505.7900 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 366 398 410.042857 $11705.2500 $28.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 154 162 133.403171 $6670.1400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 7.988891 $399.4600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 56 58 64.036506 $3201.8200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 84 86 65.911114 $3295.5700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.366667 $34.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 610 650 4902.558717 $245127.9600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 8.428571 $421.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 51 54 256.357144 $18314.1700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 143 148 779.292852 $44575.6100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 233 239 999.284922 $71389.0000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 27.928572 $1596.3900 $57.1600
SENS -V5264 EARMOLD 2 2 2.000000 $36.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 194 202 1143.305156 $81677.7700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.000000 $57.2000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 22 22 80.464285 $1116.8500 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 887 1648 8475.326568 $483143.5200 $57.0100
-------------------------------------------------------------------------------------------------------------------------------------
Total 2048 8886.558314 $494848.7700 $55.6900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 935