Summary Report for FSPSAs Initiated During the Report Period Center: 07
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: 10-01-21 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 819 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 15 16 15.219050 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 16 15.219050 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.911111 $21.4100 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.911111 $21.4100 $23.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.911111 $21.4100 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.305555 $12.7800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.911111 $26.1700 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.911111 $40.7800 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.911111 $12.4900 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.911111 $19.0300 $20.8900
EXIT -EXIT EXIT ASSESSMENT 24 24 34.122832 $1706.1400 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.444444 $22.6900 $51.0400
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Subtotal (Total Children Is Unduplicated) 28 35 43.250608 $1955.3600 $45.2100
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 124 168 112.542866 $5627.1900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 7.661112 $191.5300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 240 277 592.100203 $29605.0500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 1 1 1.466667 $73.3400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 4 3.800000 $95.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 115 122 279.366671 $13968.3600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 6.566666 $164.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 44 49 104.138892 $5206.9600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 121 229.247625 $11462.4100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 3.142857 $157.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 5.166667 $129.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 7 62.285713 $3114.2900 $50.0000
PHY -97110 PT SESSION BY LICENSED PT 2 2 11.428571 $816.4600 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 9.428571 $673.5800 $71.4400
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Subtotal (Total Children Is Unduplicated) 313 768 1429.343081 $71334.6300 $49.9100
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Total 819 1487.812739 $73289.9900 $49.2600
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Number of Children (Unduplicated) With at Least One Authorization 347