Summary Report for FSPSAs Initiated During the Report Period Center: 07
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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1142 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 23 23 166.101588 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 23 23 166.101588 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.255556 $13.1300 $51.3600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $21.3500 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 3.000000 $64.6500 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 12 12 7.417264 $61.2700 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 4.950597 $125.3000 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $34.9700 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 2.466667 $190.2600 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 2.466667 $114.5000 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 11 11 6.417264 $119.0400 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 3.466667 $71.6900 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.633333 $73.5000 $45.0000
EXIT -EXIT EXIT ASSESSMENT 55 55 37.951978 $1897.6000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.139727 $10.4800 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.139727 $7.7500 $55.4900
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 17.005479 $1275.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 26 26 10.684929 $593.0300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 20 21 2.679450 $200.9800 $75.0100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 8 4.008524 $204.6400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.087671 $4.4800 $51.0700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 15 8.575571 $437.7800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 6 6 3.738889 $190.8700 $51.0500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 123 195 125.085960 $6066.8700 $48.5000
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 0.638128 $31.9000 $49.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.400000 $92.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 87 93 73.894927 $3694.7700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 0.005556 $0.1400 $25.2000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 215 579.759687 $28987.9700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 5 6 20.738095 $1036.9100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 2.633333 $131.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.866667 $21.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 13 13 42.709523 $2135.4800 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 12.857143 $321.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 457 499 4034.133361 $201706.6100 $50.0000
INTR -T1013 INTERPRETER 3 7 51.428571 $2571.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 37.285714 $2663.6900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.428571 $138.9200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 8 9 51.857142 $3704.6800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 7.000000 $400.1200 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.800000 $364.8000 $456.0000
SENS -V5264 EARMOLD 1 1 0.800000 $14.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 38 43 311.857145 $22279.0700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 44.142856 $612.7000 $13.8800
TRAV -TRAVS Travel by mile 12 14 124.119048 $55.2300 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 494 924 5400.355467 $270965.5600 $50.1800
-------------------------------------------------------------------------------------------------------------------------------------
Total 1142 5691.543015 $277032.4300 $48.6700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 542