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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1254 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 27 28 26.858730 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 27 28 26.858730 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 6 6 15.291193 $863.8000 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.139726 $22.4600 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 7 9.263014 $217.5900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 6.139726 $85.1600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 8.000000 $189.6000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 9.317808 $84.6100 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 14.584170 $405.8800 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 5.000000 $424.2000 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 17 17 14.353425 $239.7000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.000000 $67.2000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.911111 $104.7800 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 52 52 50.200003 $2510.0000 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.126027 $9.4600 $75.0400
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 0.126027 $7.0000 $55.5300
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 40 40 1.095882 $60.8500 $55.5300
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 40 40 1.095882 $82.2300 $75.0400
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 12 12 10.516819 $536.8800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.044444 $2.2700 $51.0000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 4.088889 $208.7400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 0.488888 $24.9500 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 22 23 15.238889 $777.9500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 2.000000 $102.1000 $51.0500
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Subtotal (Total Children Is Unduplicated) 170 267 183.021923 $7569.2600 $41.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 2.000000 $10000.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 90 100 78.297629 $3914.9300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 132 152 285.328576 $14266.4500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.000000 $25.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 25 25 44.885713 $2244.2800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 16 17 23.133333 $1156.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 47 49 72.276191 $3613.8100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 2.400000 $60.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 482 504 3390.780926 $169539.0800 $50.0000
INTR -T1013 INTERPRETER 2 2 18.466667 $923.3400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 23 25 137.571428 $9828.1000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 14 14 91.438095 $6532.3500 $71.4400
SENS -V5264 EARMOLD 1 1 0.911111 $16.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 57 58 375.714279 $26841.0400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 28.142857 $390.6200 $13.8800
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Subtotal (Total Children Is Unduplicated) 527 959 4555.346805 $249862.0400 $54.8500
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Total 1254 4765.227458 $257431.3000 $54.0200
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Number of Children (Unduplicated) With at Least One Authorization 611