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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1221 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 1.966667 $72.7700 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 21 22 46.260316 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 22 23 48.226983 $72.7700 $1.5100
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.033333 $0.7800 $23.4700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.033333 $0.4600 $13.8600
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.033333 $0.3000 $9.0700
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.033333 $0.9300 $27.8000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.033333 $2.8300 $84.7600
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.033333 $1.7000 $51.0200
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 5 15.604763 $780.2400 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6 12 16.804761 $838.2900 $49.8800
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 81 113 159.637771 $7981.8900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 98 141 138.380596 $3459.5200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 36 37 61.111110 $3055.5500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 0.594445 $14.8600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 24 24 25.595237 $1279.7600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 25 30.800000 $1540.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 35 35 38.603173 $1930.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 3.594445 $89.8600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 426 469 2980.419066 $149020.9300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 1.857143 $92.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 74 87 389.995237 $27861.2600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 76 79 482.609526 $34477.6200 $71.4400
SENS -V5264 EARMOLD 1 1 0.033333 $0.6000 $17.9800
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 151 163 1139.721432 $81421.7300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 15.857143 $1132.8300 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 8.714286 $622.5500 $71.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 593 1186 5477.523943 $313981.9600 $57.3200
-------------------------------------------------------------------------------------------------------------------------------------
Total 1221 5542.555687 $314893.0200 $56.8100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 612