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: 10-01-22 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 730 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 20.233332 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 18 18 20.233332 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.450000 $3.2400 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.450000 $13.0100 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.450000 $6.2100 $13.8100
EXIT -EXIT EXIT ASSESSMENT 5 5 6.000000 $300.0000 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.455556 $126.2400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.327778 $16.8500 $51.4100
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) 12 16 12.788890 $606.7800 $47.4500
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 106 135 98.010924 $4900.6100 $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 4 4 4.666667 $116.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 239 264 572.847620 $28642.3900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 109 112 234.338095 $11716.9100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.200000 $5.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 50 108.552381 $5427.6200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.600000 $15.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 93 100 185.085709 $9254.2600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 1 1 3.714286 $185.7200 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 15 15 67.166665 $3358.3300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.928571 $46.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3 3 22.000001 $1100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 8.428571 $606.5200 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 1 1 8.428571 $606.5200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 4 4 23.142857 $1665.3600 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.285714 $16.4600 $57.6000
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Subtotal (Total Children Is Unduplicated) 308 696 1339.396632 $67713.7700 $50.5600
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Total 730 1372.418854 $68320.5500 $49.7800
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Number of Children (Unduplicated) With at Least One Authorization 328