Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1359 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 18 18 28.863493 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 28.863493 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.477778 $11.2200 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.477778 $6.6300 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.477778 $4.3400 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.477778 $13.3000 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.477778 $40.5400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.477778 $24.4000 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.477778 $7.9800 $16.7000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 4 20.000000 $1000.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 6 22.366667 $1118.3400 $50.0000
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Subtotal (Total Children Is Unduplicated) 10 17 45.711113 $2226.7400 $48.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 2 2.000000 $10000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 149 188 232.243946 $11612.2000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 74 76 54.177618 $1354.4400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 36 37 42.659523 $2132.9800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 20 21 22.842857 $1142.1500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 35 37 31.883333 $1594.1700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.000000 $50.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 27 27 33.022223 $1651.1200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.000000 $75.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 554 596 3902.738088 $195136.9500 $50.0000
INTR -T1013 INTERPRETER 2 2 4.714286 $235.7200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 79 84 484.542859 $34615.7600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 73 81 578.080952 $41298.1300 $71.4400
SENS -V5264 EARMOLD 1 1 0.477778 $8.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 151 167 1201.885708 $85862.7800 $71.4400
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Subtotal (Total Children Is Unduplicated) 707 1324 6596.269171 $386769.9700 $58.6300
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Total 1359 6670.843777 $388996.7100 $58.3100
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Number of Children (Unduplicated) With at Least One Authorization 720