Summary Report for FSPSAs Ending During the Report Period Center: 07
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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1119 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 35 35 157.640476 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 35 157.640476 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 7.207828 $407.1700 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.066667 $21.0200 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.066667 $48.5500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 4.000000 $94.8000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 15 15 34.297294 $311.4200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 18 18 35.576746 $990.1000 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.066667 $79.5100 $38.4700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 14 14 16.500816 $275.5700 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 2.724202 $61.0200 $22.4000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.311111 $150.7800 $115.0000
EXIT -EXIT EXIT ASSESSMENT 53 53 63.035520 $3151.7800 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.038356 $2.8800 $75.0900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.038356 $2.1300 $55.5600
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 33 4.923285 $273.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 30 31 0.926026 $69.4700 $75.0100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 10.573038 $539.7600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.216667 $62.1100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 1.805555 $92.1700 $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 15 16 12.588051 $642.6200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 6 6 3.927778 $200.5100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.055556 $2.7200 $48.9800
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Subtotal (Total Children Is Unduplicated) 148 230 210.946186 $7745.3100 $36.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 10.153034 $507.6500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 6.311111 $1451.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 69 80 41.946861 $2097.4000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.750000 $43.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 107 142 266.466661 $13323.3300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 9 9 29.243964 $1462.1900 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 17.833334 $891.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 42 42 72.109521 $3605.4600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 445 474 3175.661896 $158783.1700 $50.0000
INTR -T1013 INTERPRETER 3 3 4.928571 $246.4300 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 15 87.285713 $6235.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 16 16 105.276189 $7520.9300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 0.571429 $32.6600 $57.1600
SENS -V5264 EARMOLD 1 1 1.311111 $23.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 41 45 287.500002 $20538.9900 $71.4400
TRAV -TRAVS Travel by mile 3 3 28.142858 $12.5200 $0.4500
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Subtotal (Total Children Is Unduplicated) 475 854 4138.492255 $221848.6100 $53.6100
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Total 1119 4507.078917 $229593.9200 $50.9400
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Number of Children (Unduplicated) With at Least One Authorization 576