Summary Report for FSPSAs Ending During the Report Period Center: 10
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 1285 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 1 1 0.833333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.833333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 29 31 31.000000 $604.8100 $19.5100
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 11 11 11.000000 $826.4300 $75.1300
OCTH -97165 OT EVAL LOW COMPLEXITY 16 17 17.000000 $873.9700 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 17 20 19.566667 $1005.9200 $51.4100
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Subtotal (Total Children Is Unduplicated) 69 81 80.566667 $3413.9500 $42.3700
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 138 170 176.641268 $8832.0600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 18 19 16.733333 $836.6700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 46 50 40.055555 $2002.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 78 81 90.966665 $4548.3300 $50.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 12.285714 $307.1400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 568 651 4904.338117 $245216.9500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 59 65 440.241272 $31679.7400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 63 69 320.785716 $23083.7000 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 89 97 639.740479 $46035.7000 $71.9600
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Subtotal (Total Children Is Unduplicated) 684 1203 6641.788119 $362543.0500 $54.5900
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Total 1285 6723.188119 $365957.0000 $54.4300
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Number of Children (Unduplicated) With at Least One Authorization 718