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 311 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 1 1 1.000000 $23.5000 $23.5000
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 13.714286 $700.1200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 1.511111 $77.1400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 4 3.155556 $161.0900 $51.0500
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Subtotal (Total Children Is Unduplicated) 9 10 19.380953 $961.8500 $49.6300
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
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 75 75 86.077781 $4303.9100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 20 169.477778 $8473.9000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 39.714285 $2837.1900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 23.642857 $1352.3700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 13 14 59.035714 $4217.5200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 28.357143 $2025.8400 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 8.571429 $118.9700 $13.8800
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Subtotal (Total Children Is Unduplicated) 158 301 648.496840 $35010.7500 $53.9900
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Total 311 667.877793 $35972.6000 $53.8600
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Number of Children (Unduplicated) With at Least One Authorization 159