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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 901 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 13 13 18.780951 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 13 13 18.780951 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 5 5 3.055555 $42.2000 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 10.285714 $216.4100 $21.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.494444 $25.4200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 1.938889 $99.6800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.450000 $74.5400 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 17 17 21.224602 $628.3200 $29.6000
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 133 176 131.312114 $6565.6800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 3.000000 $150.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 3.583333 $89.5800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 261 297 689.047619 $34452.3800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.500000 $37.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 140 148 283.142856 $14157.1300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.966667 $24.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 37 38 67.599999 $3380.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 138 153 281.023815 $14051.2200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 4.000000 $100.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 14 14 114.995238 $5749.7700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 18 19 149.428571 $7471.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 5.000000 $359.8000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 1 1 12.714286 $914.9200 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 8 8 60.014286 $4318.6300 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 2 6.285715 $362.0600 $57.6000
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Subtotal (Total Children Is Unduplicated) 361 871 1815.614499 $92440.8700 $50.9100
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Total 901 1855.620052 $93069.1800 $50.1600
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Number of Children (Unduplicated) With at Least One Authorization 374