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 222 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
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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 1 1 1.000000 $23.5000 $23.5000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.411111 $20.9900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 1 3 2.411111 $95.5400 $39.6200
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
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 25 25 152.766667 $7638.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 21.428571 $1530.8600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.857143 $204.1100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 3 3 6.214286 $443.9500 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 47.355555 $3383.0800 $71.4400
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Subtotal (Total Children Is Unduplicated) 115 218 454.257939 $24334.6300 $53.5700
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Total 222 457.313494 $24430.1600 $53.4200
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Number of Children (Unduplicated) With at Least One Authorization 116