Summary Report for FSPSAs Ending During the Report Period Center: 52
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1058 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 1.033333 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 1.033333 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.833333 $19.1000 $10.4200
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.833333 $16.0400 $8.7500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.833333 $40.0400 $21.8400
EXIT -EXIT EXIT ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 16 16 22.656012 $1156.5900 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 1.577625 $80.5400 $51.0500
SCREEN-T1023 SCREENING 36 36 27.773454 $1388.6800 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 3.000000 $153.1500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 16 14.722222 $751.5700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 4 4 4.000000 $204.2000 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 77 85 82.229312 $3960.9600 $48.1700
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.833333 $91.6700 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 11 6.608296 $330.4200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 166 217 371.719403 $18585.9500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.533333 $13.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 93 118 229.172148 $11458.6100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 54 57 126.333329 $6316.6500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 124 131 261.324600 $13066.2200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 1.266666 $31.6700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 1.809980 $90.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 169 190 930.345787 $46517.2500 $50.0000
INTR -T1013 INTERPRETER 2 2 30.057143 $1502.8600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 61 208.554761 $14899.1300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 14 17 80.909524 $4628.0100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 32 34 170.866663 $12206.7200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 24.995239 $1428.7300 $57.1600
SENS -V5264 EARMOLD 1 1 1.222222 $22.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 112 121 575.705953 $41128.3900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 3.969047 $55.0900 $13.8800
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Subtotal (Total Children Is Unduplicated) 305 972 3027.227427 $172373.1700 $56.9400
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Total 1058 3110.490072 $176334.1300 $56.6900
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Number of Children (Unduplicated) With at Least One Authorization 321