Summary Report for FSPSAs Ending During the Report Period Center: 09
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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1417 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 20 20 46.125396 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 20 46.125396 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.038889 $0.9100 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.038889 $0.5400 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.038889 $0.3500 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.038889 $1.0800 $27.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.038889 $3.3000 $84.8600
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.038889 $1.9900 $51.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.038889 $0.6500 $16.7000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 9.571428 $478.5700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 7 11.390477 $569.5300 $50.0000
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Subtotal (Total Children Is Unduplicated) 9 17 21.234128 $1056.9200 $49.7700
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 87 135 193.444196 $9672.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 140 202 195.084514 $4877.1200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 28 30 29.644444 $1482.2200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 19 20 22.622223 $1131.1200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 36 36 34.644446 $1732.2300 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 31 33 43.926191 $2196.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 3.344444 $83.6100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 535 584 3537.695227 $176884.8000 $50.0000
INTR -T1013 INTERPRETER 1 1 8.285714 $414.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 77 458.561904 $32759.6800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 7.428571 $530.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 77 84 485.409521 $34677.6900 $71.4400
SENS -V5264 EARMOLD 1 1 0.038889 $0.7000 $18.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 160 169 1077.341266 $76965.2100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 12.142857 $867.4900 $71.4400
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Subtotal (Total Children Is Unduplicated) 702 1380 6110.614407 $344300.3700 $56.3400
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Total 1417 6177.973931 $345357.2900 $55.9000
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Number of Children (Unduplicated) With at Least One Authorization 721