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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1282 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 32 33 27.950000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 32 33 27.950000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $112.9800 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 4.000000 $78.8400 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 6.000000 $140.9400 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 6.000000 $83.2200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 18.571429 $440.1400 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 7.533333 $68.4000 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 7.000000 $194.8100 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 5.533333 $469.4500 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.533333 $78.3100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 20 20 18.352359 $306.4800 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.000000 $44.8000 $22.4000
EXIT -EXIT EXIT ASSESSMENT 55 55 53.223766 $2661.2000 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 0.139727 $10.4800 $74.9900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 0.139727 $7.7500 $55.4900
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 33 33 7.106844 $394.4400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 33 34 2.517802 $188.8600 $75.0100
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 34.050793 $1738.2900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 7.000000 $357.3500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 6 6 5.311111 $271.1300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 1.344444 $68.6300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 22 23 14.022677 $715.8500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 5 5 5.000000 $255.2500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 7 7 3.022223 $147.9100 $48.9400
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Subtotal (Total Children Is Unduplicated) 173 254 218.402901 $9192.8700 $42.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 3 3 2.112329 $10561.5000 $4999.9300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 3.521005 $176.0500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.400000 $28.6400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 4.000000 $920.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 92 107 78.027107 $3901.3900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 4 5 4.716667 $117.9200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 121 154 338.990475 $16949.5100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 1.799999 $45.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 27 57.119048 $2855.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.966667 $49.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 37.033334 $1851.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 1.466666 $36.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 52 55 110.209525 $5510.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 1.233333 $30.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 439 490 3522.171415 $176108.6600 $50.0000
INTR -T1013 INTERPRETER 3 3 41.442857 $2072.1500 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 19 130.000000 $9287.2100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.571429 $375.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 19 20 145.142856 $10369.0200 $71.4400
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 74 451.857142 $32280.6900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 17.285714 $239.9300 $13.8800
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Subtotal (Total Children Is Unduplicated) 491 995 4958.067568 $273818.3000 $55.2300
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Total 1282 5204.420469 $283011.1700 $54.3800
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Number of Children (Unduplicated) With at Least One Authorization 580