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: 10-01-18 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 1093 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 29 29 36.638888 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 29 29 36.638888 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.131507 $7.4300 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.189041 $4.4400 $23.4800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 9.000000 $213.3000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 5.000000 $45.4000 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 6.301370 $175.3700 $27.8300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 11 11 9.258752 $154.6200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 0.646575 $14.4800 $22.4000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.733333 $84.3300 $114.9900
EXIT -EXIT EXIT ASSESSMENT 56 56 48.332311 $2416.6200 $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 31 33 1.073972 $80.5700 $75.0200
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.116667 $5.9600 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 8.169863 $417.0700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 2.038888 $104.0800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.194444 $60.9700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 16 17 14.448706 $737.6100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 3 2.155556 $110.0400 $51.0500
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Subtotal (Total Children Is Unduplicated) 155 209 128.790982 $5724.2000 $44.4500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 0.767123 $38.3600 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.117808 $8.4400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 9.888889 $2274.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 75 87 44.270637 $2213.5900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.750000 $43.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 107 140 313.892860 $15694.6500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.900000 $47.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 14 14 29.971429 $1498.5700 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 29.511111 $1475.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 35 37 78.633334 $3931.6600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 420 441 3654.407963 $182720.4100 $50.0000
INTR -T1013 INTERPRETER 3 4 14.785714 $739.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 17 112.571431 $8042.1000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 4.000000 $228.8000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 16 17 135.142857 $9654.6100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 25.714286 $1469.8300 $57.1600
SENS -V5264 EARMOLD 1 1 0.733333 $13.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 59 477.766671 $34131.6300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 8.857143 $122.9400 $13.8800
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Subtotal (Total Children Is Unduplicated) 470 855 4945.682589 $269349.3000 $54.4600
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Total 1093 5111.112459 $275073.5100 $53.8200
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Number of Children (Unduplicated) With at Least One Authorization 545