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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 877 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 22 22 11.062699 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 22 22 11.062699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.044444 $0.3200 $7.1900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.044444 $1.2800 $28.8900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.044444 $0.6100 $13.8000
EXIT -EXIT EXIT ASSESSMENT 7 7 8.000000 $400.0000 $50.0000
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.344444 $17.7100 $51.4000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.8500 $51.4000
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.344444 $17.7100 $51.4000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 1.177778 $60.5500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.344444 $17.7100 $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) 13 17 11.516664 $576.1500 $50.0300
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 122 169 112.549207 $5627.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 1 1 1.000000 $50.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 5 3.541667 $88.5400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 269 303 627.827559 $31391.3900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 121 129 209.052385 $10452.6400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 59 140.766666 $7038.3300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.466667 $61.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 127 140 220.866668 $11043.3400 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 10 10 45.757143 $2287.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 8 9 54.900002 $2745.0100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.285714 $114.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 2.714285 $27.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 13.285714 $956.0400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 2 2 13.285714 $956.0400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 3 3 19.142858 $1377.5200 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.571429 $148.1100 $57.6000
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Subtotal (Total Children Is Unduplicated) 354 838 1473.013678 $74415.4600 $50.5200
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Total 877 1495.593041 $74991.6100 $50.1400
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Number of Children (Unduplicated) With at Least One Authorization 378