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: 10-01-19 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 1176 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 20 20 29.284920 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 20 20 29.284920 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 11.000000 $621.3900 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.571429 $60.4000 $23.4900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $23.7000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 6.073973 $55.1500 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 4.156164 $115.6700 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 2.000000 $169.6800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.172603 $8.8100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 14 14 14.172603 $236.6800 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.922222 $20.6600 $22.4000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.955556 $109.8900 $115.0100
EXIT -EXIT EXIT ASSESSMENT 48 48 51.900003 $2594.9900 $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 42 42 1.101362 $61.1500 $55.5200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 42 42 1.101362 $82.6400 $75.0300
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 11.000000 $561.5500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 5.000000 $255.2500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 9.633333 $491.7800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.466667 $23.8300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 29.714286 $1516.9200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 7.450000 $380.3200 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 3.483333 $177.8200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.244444 $12.4800 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 26 26 15.911111 $812.2600 $51.0500
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Subtotal (Total Children Is Unduplicated) 170 236 181.282505 $8460.5200 $46.6700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.944444 $47.2200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 88 98 83.956756 $4197.8900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 2 5.133334 $128.3400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 122 140 341.057144 $17052.8500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.066667 $51.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 31 32 73.114286 $3655.7100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 18 18 38.700002 $1935.0100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 34 36 78.961903 $3948.0900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.533334 $88.3400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 474 495 4303.411909 $215170.6400 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 17 150.160316 $10727.4600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 13 13 108.857143 $7776.7700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.142857 $465.4500 $57.1600
SENS -V5264 EARMOLD 1 1 0.955556 $17.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 53 374.819044 $26777.0600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 37.285714 $517.5200 $13.8800
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Subtotal (Total Children Is Unduplicated) 527 920 5615.100409 $297908.8100 $53.0500
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Total 1176 5825.667834 $306369.3400 $52.5900
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Number of Children (Unduplicated) With at Least One Authorization 589