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: 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 792 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
Screening, Eval, and Assessment, Class # 02
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.055555 $14.6400 $13.8700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.055555 $9.5800 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.055555 $29.3700 $27.8300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.055555 $23.6400 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.189041 $8.5100 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.189041 $21.7400 $114.9800
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 4 4 4.000000 $200.0000 $50.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.700000 $188.8900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
SCREEN-T1023 SCREENING 23 23 22.533333 $1126.6700 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 5.000000 $255.2500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 7.000000 $357.3500 $51.0500
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Subtotal (Total Children Is Unduplicated) 55 68 59.833635 $2898.2300 $48.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.622222 $3111.0000 $4999.8200
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 2 2 2.300000 $115.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.100000 $78.7700 $71.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 9 12.483333 $624.1700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 127 153 335.816665 $16790.8300 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 92 102 225.966672 $11298.3600 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 39 40 94.700001 $4735.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 90 91 190.866668 $9543.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 138 146 666.470244 $33323.5600 $50.0000
INTR -T1013 INTERPRETER 8 8 71.495240 $3574.7600 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 42 179.949205 $12855.5500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 11 11 55.400001 $3168.8700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 39 39 196.661903 $14049.5300 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.622222 $141.8600 $227.9900
SENS -V5264 EARMOLD 3 3 1.866666 $33.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 73 414.135714 $29585.8600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 6.033333 $83.7400 $13.8800
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Subtotal (Total Children Is Unduplicated) 269 724 2456.490089 $143113.8000 $58.2600
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Total 792 2516.323724 $146012.0300 $58.0300
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Number of Children (Unduplicated) With at Least One Authorization 288