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 502 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 4 4 4.000000 $78.0400 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $29.3600 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $17.6200 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 2.000000 $57.8400 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.000000 $42.0800 $21.0400
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 4 9.800001 $490.0100 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 3 4 4.000000 $205.6400 $51.4100
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Subtotal (Total Children Is Unduplicated) 12 23 28.800001 $1074.8200 $37.3200
EI Services, Class # 03
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 42 44 359.795237 $17989.7700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 10 112.357142 $8085.2300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 6 6 46.678571 $3358.9800 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 17 115.109524 $8283.2800 $71.9600
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Subtotal (Total Children Is Unduplicated) 255 478 1070.546829 $59547.6200 $55.6200
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Total 502 1099.380163 $60622.4300 $55.1400
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Number of Children (Unduplicated) With at Least One Authorization 262