Summary Report for FSPSAs Initiated During the Report Period Statewide
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: 07-01-16 and 09-30-16 Date of Report: 10-26-16 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 24867 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 159 165 297.266135 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 7 7 29.891270 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 15 15 12.644446 $467.8500 $37.0000
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Subtotal (Total Children Is Unduplicated) 181 187 339.801851 $467.8500 $1.3800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 95 117 60.850453 $2951.2500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 2.738888 $128.9700 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.316667 $19.6600 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 128 132 87.455554 $1679.1400 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.000000 $31.2600 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 48 48 25.384975 $557.2000 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 16 16.266787 $142.3300 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $8.0600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 20 16.171548 $353.1900 $21.8400
AUDE -92585 AUD EVOKED RESPONSE (COMP) 17 17 6.644445 $432.8200 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $38.3700 $38.3700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 13 13 3.534247 $80.9400 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 18 18 8.644444 $220.6900 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 4.093608 $191.5900 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 15 15 7.109816 $850.3100 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 21 28 15.310539 $765.5500 $50.0000
EXIT -EXIT EXIT ASSESSMENT 300 324 408.384669 $20419.2300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 3 0.232876 $17.4600 $74.9800
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 0.355556 $19.7400 $55.5100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 43 48 44.774099 $3358.0700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 24 33 18.446117 $1383.4800 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 8.505174 $637.8900 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 29 34 29.782191 $2233.6700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 48 63 43.265309 $2401.2100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 493 493 473.655682 $35524.5200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 189 189 139.153383 $10436.6900 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 122 122 106.858877 $8014.5100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 451 454 568.041952 $31526.3900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 182 190 232.307559 $17423.0800 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 1.000000 $50.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 9 9 34.871428 $1743.5800 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 25 25 12.324234 $629.1600 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 235 238 131.262615 $6700.9800 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 28 28 23.160395 $1182.3400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 188 190 108.829505 $5555.7400 $51.0500
SCREEN-T1023 SCREENING 37 38 22.788664 $1139.4400 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.894977 $13.9600 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.145205 $109.5100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 2.398783 $122.4600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 286 299 187.208967 $9557.0000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 27 28 20.358992 $1039.3300 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 3 3 1.688889 $84.4500 $50.0000
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Subtotal (Total Children Is Unduplicated) 2097 3280 2883.218069 $169775.1800 $58.8800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 103 115 52.366827 $261834.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.066666 $53.3300 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 38 39 290.276407 $14513.8200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 0.972222 $69.6200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 5.970875 $1428.2600 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 808 938 570.455964 $28522.8900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 59 63 38.809637 $970.2400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1761 2213 3048.299245 $152414.8300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 95 106 155.336503 $3883.4100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 468 531 765.009144 $38250.4700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 27 30 29.255555 $731.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 428 466 615.992071 $30799.6100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 12 13 11.772224 $294.3100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1117 1193 1464.193158 $73209.6600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 70 80 173.920634 $4348.0200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 15.888888 $1164.9700 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 25.714286 $642.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 266 312 3167.495264 $79187.4000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 13 14 66.697327 $3334.8700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4894 5351 32862.951120 $1643148.8700 $50.0000
INTR -T1013 INTERPRETER 128 156 531.938597 $26596.9700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3115 4778 20816.596627 $208166.0700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 652 703 4000.439804 $285791.4600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 104 108 573.785714 $32820.5700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 697 750 3981.848423 $284463.2600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 58 61 252.528181 $14434.5000 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 6 1.298402 $84.3900 $64.9900
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.894977 $106.1000 $118.5500
SENS -V5050 IN EAR MONAURAL HEARING AID 8 8 2.395890 $568.0900 $237.1100
SENS -V5060 BEHIND EAR HEARING AID
2 2 0.238357 $56.5100 $237.0600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 5 5 1.985160 $941.4600 $474.2500
SENS -V5264 EARMOLD 31 31 26.077265 $469.3900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1104 1217 6806.564516 $486261.2300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 7 33.047618 $1890.3300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 37 39 181.885711 $2524.5800 $13.8800
TRAV -TRAVS Travel by mile 1162 2037 127242.971148 $56623.1300 $0.4500
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Subtotal (Total Children Is Unduplicated) 6753 21400 207816.940407 $3740601.2900 $18.0000
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Total 24867 211039.960327 $3910844.3100 $18.5300
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Number of Children (Unduplicated) With at Least One Authorization 7166