Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 821 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 16 16 8.880952 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 8.880952 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
EXIT -EXIT EXIT ASSESSMENT 7 7 9.000000 $450.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.316667 $16.2800 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.183333 $9.4200 $51.4000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.316667 $16.2800 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.283333 $14.5600 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 1.400000 $71.9700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.183333 $9.4200 $51.4000
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 14 17 13.683333 $663.0300 $48.4600
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 2.283333 $114.1700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 115 152 86.591477 $4329.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 2 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 7.400000 $185.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 262 298 590.966657 $29548.2900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 119 125 202.166668 $10108.3400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 1 1 0.433333 $21.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 59 111.209520 $5560.4600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 114 121 203.564281 $10178.1900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 2.857143 $142.8600 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 9 9 36.876189 $1843.8100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4 5 23.014286 $1150.7100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 9.142857 $457.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 12.857143 $925.2000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 3 3 13.457143 $968.3800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2 2 14.285715 $1028.0000 $71.9600
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Subtotal (Total Children Is Unduplicated) 334 788 1318.105745 $66611.8200 $50.5400
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Total 821 1340.670030 $67274.8500 $50.1800
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Number of Children (Unduplicated) With at Least One Authorization 350