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: 10-01-17 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 1040 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 1.000000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.211111 $44.8100 $37.0000
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Subtotal (Total Children Is Unduplicated) 3 3 2.211111 $44.8100 $20.2700
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.041096 $0.5200 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.041096 $0.3400 $8.2600
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.041096 $0.8500 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.041096 $1.8500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.041096 $4.7300 $115.0100
EXIT -EXIT EXIT ASSESSMENT 7 7 7.000000 $350.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 7.000000 $357.3500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 3.063014 $156.3700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.688889 $35.1700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
SCREEN-T1023 SCREENING 33 34 28.793759 $1439.6900 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 2.156165 $110.0700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 17 17 16.388888 $836.6500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 3.000000 $153.1500 $51.0500
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Subtotal (Total Children Is Unduplicated) 72 88 74.296195 $3753.0200 $50.5100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.071233 $356.0000 $4997.6800
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 1.466667 $73.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 5 5 3.012500 $150.6300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 152 186 384.346826 $19217.3500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.266667 $56.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 106 129 269.106351 $13455.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.750000 $18.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 60 61 122.511110 $6125.5500 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 134 142 270.333333 $13516.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 6.200000 $155.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 4.579615 $228.9800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 169 186 895.460314 $44773.0300 $50.0000
INTR -T1013 INTERPRETER 2 2 12.766667 $638.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 54 58 235.776189 $16843.8600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 20 20 113.728569 $6505.2800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 40 41 164.341665 $11740.5700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 2 2 7.267857 $415.4300 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 2 2 1.133334 $20.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 91 102 475.427370 $33964.5500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 6.000000 $83.2800 $13.8800
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Subtotal (Total Children Is Unduplicated) 276 949 2977.546267 $168566.9800 $56.6100
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Total 1040 3054.053573 $172364.8100 $56.4400
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Number of Children (Unduplicated) With at Least One Authorization 295