Summary Report for FSPSAs Initiated During the Report Period Center: 52
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 958 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
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Subtotal (Total Children Is Unduplicated) 1 1 1.000000 $0.0000 $0.0000
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 8 8 8.000000 $400.0000 $50.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 3.093151 $157.9100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 8.428571 $430.2800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.688889 $35.1700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.049315 $155.6700 $51.0500
SCREEN-T1023 SCREENING 27 28 24.812633 $1240.6300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.000000 $459.4500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 3.134247 $160.0000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 11.000000 $561.5500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 4 4 4.000000 $204.2000 $51.0500
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Subtotal (Total Children Is Unduplicated) 73 85 76.412286 $3864.1900 $50.5700
EI Services, Class # 03
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.500000 $25.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 2.100000 $150.3800 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 7 7 7.279167 $363.9600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 154 172 413.051587 $20652.5800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 104 118 304.396827 $15219.8500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.750000 $18.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 55 58 146.800002 $7340.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 112 116 274.633335 $13731.6800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.892857 $44.6500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 174 184 1111.388903 $55569.3800 $50.0000
INTR -T1013 INTERPRETER 3 3 41.547619 $2077.3800 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 52 59 276.420639 $19747.4700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 20 21 129.995240 $7435.7300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 29 30 129.909522 $9280.7300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 10.157143 $580.5800 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 2 2 2.266667 $40.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 92 500.188097 $35733.3900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 5.000000 $286.0000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 9.857143 $136.8200 $13.8800
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Subtotal (Total Children Is Unduplicated) 298 872 3368.134748 $188663.1200 $56.0100
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Total 958 3445.547034 $192527.3100 $55.8800
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Number of Children (Unduplicated) With at Least One Authorization 320