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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 866 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 0.588889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.588889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.5800 $14.5800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $9.7900 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $28.7200 $28.7200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $13.7100 $13.7100
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 8.000000 $408.4000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 7.000000 $357.3500 $51.0500
SCREEN-T1023 SCREENING 29 32 39.428571 $1971.4300 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 8.666667 $442.4400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 9 9 8.266667 $368.2800 $44.5500
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Subtotal (Total Children Is Unduplicated) 56 72 79.361905 $3817.8500 $48.1100
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 155 190 376.166664 $18808.3200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.750000 $18.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 98 242.199998 $12109.9900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 47 49 106.499999 $5325.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 102 108 207.066662 $10353.3100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 182 201 877.185711 $43859.2900 $50.0000
INTR -T1013 INTERPRETER 2 2 8.076190 $403.8100 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 22 91.109523 $6508.8600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 1.233333 $88.1100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 38.285715 $2189.9400 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 3 4 20.309524 $1161.7000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 31 31 149.328571 $10668.0300 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 69 78 375.592063 $26832.3100 $71.4400
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.466667 $62.0000 $13.8800
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Subtotal (Total Children Is Unduplicated) 264 793 2498.270620 $138389.4000 $55.3900
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Total 866 2578.221414 $142207.2500 $55.1600
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Number of Children (Unduplicated) With at Least One Authorization 270