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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1457 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 1 1 0.644444 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 0.644444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 188 191 190.231746 $4470.4500 $23.5000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 11 8.211111 $419.1800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 12 12.000000 $612.6000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.400000 $122.5200 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 3.266667 $166.7700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 6.655556 $339.7700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 21 21 20.422222 $1042.5500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $133.6500 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 228 258 251.187302 $7562.7300 $30.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 86 89 121.658732 $6082.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 13 14 15.766667 $788.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 26 36.265872 $1813.2900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 47 47 47.044446 $2352.2300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.900000 $47.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 469 509 3424.302379 $171215.0900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 126 130 851.809529 $60853.2300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.857143 $204.1100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 12 13 75.821430 $4336.9800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 166 172 1014.359526 $72465.8100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.928571 $281.7200 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 24.571429 $1404.5000 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 173 180 1140.135713 $81451.2900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 21.785714 $1556.3700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.357143 $77.6300 $57.2000
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 5.000000 $69.4000 $13.8800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 656 1198 6794.564294 $415510.4300 $61.1500
-------------------------------------------------------------------------------------------------------------------------------------
Total 1457 7046.396040 $423073.1700 $60.0400
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 688