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: 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 1390 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 16 16 30.423809 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 16 16 30.423809 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 6.000000 $338.9400 $56.4900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.676190 $6.1400 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 10.247619 $285.1900 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 2 2.000000 $169.6800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.169863 $8.6800 $51.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 10 9.533333 $159.2100 $16.7000
EXIT -EXIT EXIT ASSESSMENT 60 61 53.030594 $2651.5400 $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 15 15 8.468493 $470.0100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 15 15 8.468493 $635.1500 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 7.433333 $379.4700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 19 19 16.638889 $849.4200 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 6.000000 $306.3000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 23.072222 $1177.8400 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 6.688889 $341.4700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 31 32 28.208295 $1440.0300 $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 3 3 2.305556 $102.7100 $44.5500
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Subtotal (Total Children Is Unduplicated) 168 208 202.974645 $10074.2200 $49.6300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.210959 $1055.0000 $5000.9700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 1 1 1.000000 $50.0000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 2.000000 $460.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 103 116 84.199612 $4210.0300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 14 16 12.894445 $322.3600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 162 177 397.357146 $19867.8700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 3 3 3.857143 $96.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 71 108.100000 $5405.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 25 61.947619 $3097.3800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 1.000000 $25.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 60 70 115.028571 $5751.4300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.833333 $70.8300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 494 529 4025.330956 $201266.5900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 13 13 69.571427 $3478.5700 $50.0000
INTR -T1013 INTERPRETER 3 4 12.652381 $632.6200 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 45 291.641270 $20834.8600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 5.142857 $367.4100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 2 2 11.142857 $637.3700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 21.714286 $1242.0600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 21 24 194.000000 $13859.3600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 1.428571 $102.0600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.285714 $244.9700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 42 47 353.000000 $25218.3500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 12.428571 $887.9000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 82.285714 $1142.1200 $13.8800
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Subtotal (Total Children Is Unduplicated) 570 1166 5875.053432 $310325.5600 $52.8200
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Total 1390 6108.451886 $320399.7800 $52.4500
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Number of Children (Unduplicated) With at Least One Authorization 615