Summary Report for FSPSAs Initiated During the Report Period Center: 09
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: 01-01-16 and 03-31-16 Date of Report: 05-12-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 98 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 2 1.900000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 2 1.900000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.955556 $18.3500 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.955556 $9.9600 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.955556 $8.3600 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.955556 $20.8700 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.955556 $62.2500 $65.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.955556 $21.8800 $22.9000
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Subtotal (Total Children Is Unduplicated) 1 6 5.733336 $141.6700 $24.7100
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.955556 $47.7800 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 33 44 0.647938 $32.4100 $50.0100
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 0.006850 $0.1700 $24.8200
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 8 1.448411 $72.4200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 0.101370 $5.0700 $50.0100
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1 1 0.005556 $0.2800 $50.4000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6 6 37.285714 $1864.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 6 16.614286 $1186.9300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 4 4 24.357143 $1740.0700 $71.4400
SENS -V5264 EARMOLD 1 1 0.900000 $16.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 16 16 71.214287 $5087.5500 $71.4400
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Subtotal (Total Children Is Unduplicated) 53 90 153.537111 $10053.1600 $65.4800
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Total 98 161.170447 $10194.8300 $63.2500
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Number of Children (Unduplicated) With at Least One Authorization 54