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: 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 13482 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 147 148 219.414384 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 15 15 51.025397 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 160 164 270.689781 $9.2500 $0.0300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 75 95 80.314844 $3895.2800 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.285714 $19.2000 $14.9300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 25 25 23.957936 $459.9900 $19.2000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.285714 $13.4000 $10.4200
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 9.954761 $218.5100 $21.9500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.285714 $11.2500 $8.7500
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.285714 $10.3600 $8.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.285714 $28.0800 $21.8400
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.285714 $37.1600 $28.9000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 4 1.780159 $115.9600 $65.1400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 11 7.219047 $184.3000 $25.5300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 4 1.494445 $69.9400 $46.8000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.224658 $146.4700 $119.6000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 11 13 5.571611 $278.5800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 247 258 437.324675 $21866.2200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 2.922221 $219.1600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 11 3.383332 $253.7400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.216667 $16.2500 $75.0100
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 6 12.764286 $957.3200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 15 15 16.539247 $917.9200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 17.782190 $1333.6700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 7.510958 $563.3300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 5.505479 $412.9100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 18 18 24.030136 $1333.6800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 7 7.276864 $545.7700 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 3.285714 $164.2900 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 9 2.472223 $126.2100 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 28 28 15.507895 $791.6800 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 9 1.088205 $55.5500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 15 17 7.403121 $377.9400 $51.0500
SCREEN-T1023 SCREENING 5 5 3.011111 $150.5600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 3 1.977778 $30.8500 $15.6000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.084932 $4.3300 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 40 42 17.370781 $886.8000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 3 3 0.143652 $7.3400 $51.0700
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Subtotal (Total Children Is Unduplicated) 506 627 727.833212 $36628.9900 $50.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 27 35 11.939193 $59696.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.022222 $51.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 13 13 96.710329 $4835.5200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.616666 $147.4900 $239.1700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 608 755 457.780547 $22889.1500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 45 51 25.773478 $644.3400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1722 2113 2896.140820 $144806.9200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 127 139 341.462700 $8536.5700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 533 643 985.867768 $49293.3200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 28 38 43.804760 $1095.1200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 410 447 676.502287 $33825.0700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 13 16.456348 $411.4100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1187 1242 1523.406398 $76170.2900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 112 132 339.996827 $8499.9300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.466667 $34.2200 $73.3300
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 9.714286 $242.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 41.428571 $2071.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 7 29.457141 $1472.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 209 233 1494.497618 $74724.8700 $50.0000
INTR -T1013 INTERPRETER 113 132 550.553196 $27527.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2861 4471 21057.857741 $210578.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 73 78 506.035715 $36151.1500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 19 21 115.114284 $6584.5400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 95 97 565.471428 $40397.2900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 10 66.000000 $3772.5600 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.128767 $8.3700 $65.0200
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 3.224658 $764.6400 $237.1200
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 3 5 1.806544 $856.7100 $474.2300
SENS -V5264 EARMOLD 6 8 6.066667 $109.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 154 165 988.423813 $70613.0000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.285714 $73.5400 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 73.785715 $1024.1500 $13.8800
TRAV -TRAVS Travel by mile 1043 1823 132963.976112 $59168.9700 $0.4500
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Subtotal (Total Children Is Unduplicated) 4775 12691 165892.774980 $947078.6100 $5.7100
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Total 13482 166891.297973 $983716.8500 $5.8900
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Number of Children (Unduplicated) With at Least One Authorization 5022