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: 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 1268 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 21 21 15.144444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 21 15.144444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.4900 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 7 11.305556 $265.5700 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 4.000000 $55.4800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 5.000000 $118.5000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 7 7.000000 $63.5600 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 16 14.720547 $409.6700 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 4.000000 $339.3600 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 18 19 19.000000 $317.3000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 3.000000 $67.2000 $22.4000
EXIT -EXIT EXIT ASSESSMENT 52 52 54.109284 $2705.4700 $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 34 34 7.178077 $398.3900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 33 34 1.189035 $89.2000 $75.0200
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 8.000000 $408.4000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 18 18 15.155555 $773.6900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 5.000000 $255.2500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 4.860959 $248.1500 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.172223 $8.8000 $51.0700
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 12.405555 $633.3000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.076712 $3.7500 $48.9300
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Subtotal (Total Children Is Unduplicated) 168 247 181.452957 $7427.3800 $40.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.071233 $3.5600 $49.9800
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 5.211111 $1198.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 94 107 78.819169 $3940.9900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 5 7 5.666667 $141.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 131 153 306.799992 $15339.9700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 7.066666 $176.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 27 28 47.633333 $2381.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 2 2.833334 $70.8400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 17 17 27.476189 $1373.8100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.833333 $70.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 42 42 80.761903 $4038.0900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.233333 $80.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 482 516 3827.116703 $191355.8100 $50.0000
INTR -T1013 INTERPRETER 1 1 19.433333 $971.6700 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 29 261.142858 $18656.0600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 6.571429 $375.8800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 16 16 111.285714 $7950.2600 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.422222 $192.5200 $455.9800
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 55 60 454.607146 $32477.1500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 10.714286 $612.8600 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 43.571429 $604.7700 $13.8800
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Subtotal (Total Children Is Unduplicated) 536 1000 5304.271383 $287014.4400 $54.1100
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Total 1268 5500.868784 $294441.8200 $53.5300
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Number of Children (Unduplicated) With at Least One Authorization 601