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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1341 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 17 17 11.933332 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 17 17 11.933332 $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 6 6 9.205556 $216.2400 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 3.000000 $41.6100 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 5.000000 $118.5000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 5.000000 $45.4000 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 11.043835 $307.3500 $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 -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 0.249315 $12.7400 $51.0900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 19 19 19.000000 $317.3000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 2.000000 $44.8000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.197260 $8.8800 $45.0100
EXIT -EXIT EXIT ASSESSMENT 57 57 54.656011 $2732.8000 $50.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 0.016438 $1.2400 $75.2800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 8.016438 $444.9200 $55.5000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 17 17 8.372602 $464.6900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 17 8.372602 $627.9600 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 6.571429 $335.4700 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 5.000000 $255.2500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 14.089268 $719.2500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.472222 $24.1100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 7.000000 $357.3500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 4.149393 $211.8300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 24 25 18.430517 $940.8700 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.172603 $7.6900 $44.5500
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Subtotal (Total Children Is Unduplicated) 161 219 196.015489 $8670.5500 $44.2300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.210959 $1055.0000 $5000.9700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 0.246575 $12.3300 $50.0100
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.800000 $874.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 95 108 84.230962 $4211.6000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 11 13 5.672223 $141.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 154 175 361.721422 $18086.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 42 44 72.883334 $3644.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.166667 $54.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 24 24 54.038094 $2701.9100 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 51 53 79.414287 $3970.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 524 566 4285.630940 $214281.5800 $50.0000
INTR -T1013 INTERPRETER 2 3 11.285714 $564.2900 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 33 35 271.571428 $19401.0400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.142857 $153.0900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 16 18 141.857142 $10134.2800 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.600000 $729.6000 $456.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 49 53 379.428567 $27106.3800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.714286 $98.0600 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 22.428571 $311.3100 $13.8800
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Subtotal (Total Children Is Unduplicated) 567 1105 5784.044028 $307581.3700 $53.1800
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Total 1341 5991.992849 $316251.9300 $52.7800
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Number of Children (Unduplicated) With at Least One Authorization 620