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: 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 496 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 165 165 171.734921 $4034.0500 $23.4900
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $133.6500 $44.5500
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Subtotal (Total Children Is Unduplicated) 170 171 177.734921 $4320.8500 $24.3100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 126 132 112.555551 $5627.7600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 11 12 11.544445 $577.2300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 62 64 42.961105 $2148.0300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 66 68 49.333335 $2466.6800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 21 171.528573 $8576.4200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 7.000000 $500.0800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 6 41.000000 $2345.2000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 7 7 42.571428 $3041.3000 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 13 13 86.709522 $6194.5300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.000000 $457.6000 $57.2000
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Subtotal (Total Children Is Unduplicated) 170 325 573.203959 $31934.8100 $55.7100
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Total 496 750.938880 $36255.6700 $48.2800
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Number of Children (Unduplicated) With at Least One Authorization 301