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: 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 1917 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 -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $23.5000 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 265 265 277.628570 $6524.2700 $23.5000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 35 36 72.077778 $3679.5700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 5.066667 $258.6500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 9.428571 $481.3300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 36 43 40.522223 $2068.6600 $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) 330 361 411.723809 $13329.2900 $32.3700
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 11.428571 $2628.5800 $230.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 126 128 163.729373 $8186.5200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 26 23.277780 $1163.9000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 26 26 45.612700 $2280.6400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 76 76 86.966670 $4348.3500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 516 619 4675.900380 $233794.9700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 177 190 1233.411099 $88114.9800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 11 12 82.357142 $4710.8400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 223 235 1261.552377 $90125.3900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 8 8 36.142856 $2065.9300 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 208 220 1427.326979 $101968.3100 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 9 9 41.142857 $571.0700 $13.8800
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Subtotal (Total Children Is Unduplicated) 763 1556 9090.848784 $540078.3300 $59.4100
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Total 1917 9502.572593 $553407.6200 $58.2400
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Number of Children (Unduplicated) With at Least One Authorization 784