Summary Report for FSPSAs Ending During the Report Period Center: 52
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 890 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 3 3 1.544444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.544444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.277778 $4.0500 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.277778 $2.7200 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.277778 $7.9800 $28.7200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.277778 $26.6900 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.298630 $13.4400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.528767 $60.8100 $115.0100
EXIT -EXIT EXIT ASSESSMENT 3 3 3.000000 $150.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 8 9.833333 $501.9900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 10 10 10.000000 $510.5000 $51.0500
SCREEN-T1023 SCREENING 42 43 43.000000 $2150.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 6.000000 $306.3000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 5.000000 $222.7500 $44.5500
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Subtotal (Total Children Is Unduplicated) 75 87 82.771842 $4110.3800 $49.6600
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 2.800000 $140.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 1.500000 $75.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 146 169 388.097618 $19404.8800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 95 112 237.966667 $11898.3400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 38 79.233336 $3961.6800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 114 119 237.533335 $11876.6800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 5.133333 $128.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 155 164 783.482150 $39174.1200 $50.0000
INTR -T1013 INTERPRETER 6 6 47.514285 $2375.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 30 33 101.388097 $7243.1600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 10 40.995238 $2344.9400 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 4.504762 $257.6700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 28 28 113.848807 $8133.3700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.100000 $150.0200 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 2.277778 $519.3400 $228.0000
SENS -V5264 EARMOLD 2 2 2.144445 $38.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 98 107 572.947621 $40931.3700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.000000 $500.0800 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 9.142858 $126.9000 $13.8800
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Subtotal (Total Children Is Unduplicated) 270 800 2639.610330 $149280.1800 $56.5500
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Total 890 2723.926616 $153390.5600 $56.3100
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Number of Children (Unduplicated) With at Least One Authorization 279