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: 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 2717 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
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 2.000000 $31.6800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 60 64 64.000000 $1248.6400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.000000 $71.0100 $23.6700
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 297 326 360.151077 $27058.1400 $75.1300
OCTH -97165 OT EVAL LOW COMPLEXITY 63 81 95.115871 $4889.8900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.733333 $37.7000 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 11 16 15.511111 $797.4300 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 86 105 108.530158 $5579.5300 $51.4100
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Subtotal (Total Children Is Unduplicated) 440 598 649.041550 $39714.0300 $61.1900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 16.142857 $80714.5000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1 1 0.866667 $43.3400 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 146 182 166.144443 $8307.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 12 15.844443 $792.2200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 48 54 47.222223 $2361.1200 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 94 111 108.122222 $5406.1100 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 38 44 181.952775 $9097.6400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 609 709 5135.619059 $256781.0200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 2.565079 $128.2600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 212 304 1704.587303 $122662.0700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 201 276 1361.628571 $97982.7500 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 301 421 2262.454767 $162806.2300 $71.9600
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Subtotal (Total Children Is Unduplicated) 907 2119 11003.150409 $747082.4500 $67.9000
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Total 2717 11652.191959 $786796.4700 $67.5200
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Number of Children (Unduplicated) With at Least One Authorization 1075