Summary Report for FSPSAs Initiated During the Report Period Center: 10
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 3074 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 0.033333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.033333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 275 278 278.000000 $5423.7800 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 225 227 227.000000 $3332.3600 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 227 229 229.000000 $2017.4900 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 224 226 226.000000 $6535.9200 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 226 228 228.000000 $4797.1200 $21.0400
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 4 9.800001 $490.0100 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 47 55 65.023809 $3342.8700 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 12 14 24.000000 $1233.8400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 55 66 72.714286 $3738.2400 $51.4100
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Subtotal (Total Children Is Unduplicated) 363 1329 1361.538096 $30986.7100 $22.7600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 3 3.000000 $15000.0000 $5000.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 175 204 231.152385 $11557.6600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 26 30 17.766666 $888.3300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 45 47 47.711112 $2385.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 109 118 133.226985 $6661.3500 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 6.571429 $328.5700 $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 545 673 4762.505173 $238125.2600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 166 185 1220.214290 $87806.5800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 176 207 1119.261900 $80542.1100 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 225 275 1677.323816 $120700.2100 $71.9600
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Subtotal (Total Children Is Unduplicated) 826 1744 9218.911534 $564004.5100 $61.1800
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Total 3074 10580.482963 $594991.2200 $56.2300
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Number of Children (Unduplicated) With at Least One Authorization 870