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: 10-01-23 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 783 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.866667 $32.2400 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 2 2 0.866666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.733333 $32.2400 $18.6000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 12 12 12.000000 $234.1200 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 9.000000 $132.1200 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 8.000000 $70.4800 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 8.000000 $231.3600 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 8.000000 $168.3200 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 7 7 7.000000 $525.9100 $75.1300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 5 4.300000 $215.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 8 8.000000 $411.2800 $51.4100
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Subtotal (Total Children Is Unduplicated) 33 70 69.300000 $2245.6400 $32.4000
EI Services, Class # 03
CONIF -CONIF CONSULT, ITDS FACE TO FACE 201 264 283.893655 $14194.7200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 30 34 40.122221 $2006.1100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 73 91 71.744442 $3587.2100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 113 133 140.709528 $7035.4900 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 9.119048 $455.9500 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.177778 $8.8900 $50.0100
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 93 106 682.998409 $34149.9500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 20 122.214287 $8794.5300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 18 19 115.857141 $8337.0800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 35 39 311.928573 $22446.3700 $71.9600
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Subtotal (Total Children Is Unduplicated) 331 710 1778.765082 $101016.2900 $56.7900
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Total 783 1849.798415 $103294.1700 $55.8400
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Number of Children (Unduplicated) With at Least One Authorization 348