Summary Report for FSPSAs Ending During the Report Period Statewide
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: 10-01-16 and 12-31-16 Date of Report: 02-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 26197 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.250000 $9.2500 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 135 137 247.511904 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 10 11 32.465079 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 11 11 5.233334 $193.6400 $37.0000
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Subtotal (Total Children Is Unduplicated) 156 160 285.460317 $202.8900 $0.7100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 115 129 75.808592 $3676.7300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 19 19 20.422557 $961.6900 $47.0900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 4.035616 $60.2500 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 267 267 103.811115 $1993.1800 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 4.868949 $50.7300 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 38 38 15.661851 $343.7800 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 3.773514 $33.0200 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $8.0600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 3.717959 $81.2000 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $57.8000 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 19 21 6.682879 $435.3400 $65.1400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 2.416667 $92.7300 $38.3700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 5 5 0.506848 $11.6100 $22.9000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 11 2.668339 $68.1200 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 11 8.428571 $394.4600 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 14.063959 $1682.0500 $119.6000
EVAL -96111 DEVELOPMENTAL EVALUATION 17 19 10.160727 $508.0400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 263 275 345.203905 $17260.2200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 0.723288 $54.2400 $74.9900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 47 57 50.192312 $3764.4400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 23 32 20.816515 $1561.2500 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 16 16 17.265601 $1294.9200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 23 25 26.838812 $2012.9100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 57 79 60.941098 $3382.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 475 478 614.030321 $46052.5800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 184 184 189.046330 $14178.6200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 120 120 125.431488 $9407.4200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 439 440 684.002029 $37962.2100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 148 168 194.836974 $14612.7800 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 1.142857 $57.1500 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 13 15 28.947620 $1447.3900 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 30 30 9.815524 $501.0800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 258 268 146.278373 $7467.5100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 37 42 32.150817 $1641.3000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 220 227 103.561750 $5286.8200 $51.0500
SCREEN-T1023 SCREENING 43 43 29.850548 $1492.5400 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 2 1.888889 $29.4700 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 5.084932 $259.5800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.038356 $53.0100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 305 322 210.096790 $10725.4600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 18 18 16.473777 $840.9700 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 1.177778 $58.8900 $50.0000
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Subtotal (Total Children Is Unduplicated) 2254 3420 3196.864827 $191863.7700 $60.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 118 128 74.502925 $372514.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 5 2.433333 $121.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 41 41 37.078562 $1853.9300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 6 6 7.009523 $501.9500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 20 20 13.173201 $3151.0300 $239.2000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 769 931 560.480777 $28024.2000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 90 95 54.240164 $1356.0100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1960 2514 3005.972468 $150298.5700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 126 160 379.720634 $9493.0200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 545 631 792.580228 $39628.9200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 11 11 31.011111 $775.2800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 466 491 638.764206 $31938.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 11 30.014285 $750.3600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1251 1339 1440.229768 $72011.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 87 103 288.455553 $7211.4000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 13 20.302381 $1488.5700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 207 232 2439.626982 $60990.6600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 91.571429 $4578.5700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 8 46.305218 $2315.2700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5107 5671 33032.689702 $1651633.8200 $50.0000
INTR -T1013 INTERPRETER 134 149 633.250716 $31662.5300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3063 4829 20310.127493 $203101.1400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 742 818 4327.156361 $309131.9600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 103 114 550.540479 $31490.9100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 782 842 4252.227097 $303779.0000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 68 72 321.168674 $18358.0000 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 0.888128 $57.7300 $65.0100
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.377778 $44.7900 $118.5700
SENS -V5050 IN EAR MONAURAL HEARING AID 10 10 9.645054 $2287.0500 $237.1200
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.079452 $18.8500 $237.2600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 5 6 4.815177 $2283.5600 $474.2400
SENS -V5264 EARMOLD 28 30 36.621024 $659.1700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1284 1411 7485.867641 $534790.2600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 22.857143 $1307.4300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 33 34 210.539886 $2922.3000 $13.8800
TRAV -A0160 *PROV TRAVEL TO NATURAL ENV-BY MIN 2 3 5.285714 $2.6400 $0.5000
TRAV -TRAVS Travel by mile 1222 1877 110930.225702 $49363.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7241 22617 192087.835969 $3931898.1000 $20.4700
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Total 26197 195570.161113 $4123964.7600 $21.0900
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Number of Children (Unduplicated) With at Least One Authorization 7922