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: 01-01-17 and 03-31-17 Date of Report: 05-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 26086 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 191 196 389.665344 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 8 8 50.221430 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 8 8 5.130159 $189.8200 $37.0000
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Subtotal (Total Children Is Unduplicated) 205 212 445.016933 $189.8200 $0.4300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 95 114 50.894296 $2468.3800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 3.255557 $167.1800 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 6.202381 $111.1500 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 219 219 157.146825 $3355.0800 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 6.085714 $76.7400 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 52 52 36.651742 $789.8500 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 17 17 9.451826 $78.0700 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 5.085714 $46.0800 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 21 21 27.799444 $703.6100 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 4.085714 $142.8800 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 20 20 9.491270 $732.0600 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $46.4200 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 13 13 3.468493 $64.3400 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 17 17 13.791270 $285.2000 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 15 10.215144 $459.6800 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 18 20 10.591933 $1218.0800 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 0.123288 $15.4100 $125.0100
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 20 30 24.310345 $1215.5300 $50.0000
EXIT -EXIT EXIT ASSESSMENT 292 307 488.057706 $24402.8800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.550000 $41.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 54 61 46.833709 $3512.5400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 38 57 44.830286 $3362.2700 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 8 17.450487 $1308.8000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 30 30 30.408524 $2280.6300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 62 82 72.075948 $4000.2000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 514 514 594.792726 $44609.6000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 252 253 350.889700 $26316.8200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 129 129 134.533536 $10090.0300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 475 476 537.150667 $29811.8800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 211 217 237.846418 $17838.5000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.002740 $0.1400 $49.2700
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 11 12 44.190475 $2209.5200 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 20 20 5.224169 $266.7000 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 2.888889 $147.4800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 178 183 76.286662 $3894.4300 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 2.289955 $116.9000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 6.583638 $336.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 61 63 39.999162 $2041.9600 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 26 26 9.000349 $459.4600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 8 3.185159 $162.6000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 128 128 137.325715 $7010.5100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 2.740107 $139.8900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 4.133638 $211.0200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 56 59 37.217514 $1899.9600 $51.0500
SCREEN-T1023 SCREENING 30 31 19.179376 $958.9700 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 1.034399 $15.5200 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 4.449390 $227.1400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 331 343 273.509470 $13962.6900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 21 21 17.523167 $894.5500 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.211111 $10.5600 $50.0000
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Subtotal (Total Children Is Unduplicated) 2361 3645 3626.045748 $214869.2900 $59.2600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 108 125 59.124247 $295622.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 5 5.300001 $265.0100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 33 33 211.501067 $10575.0600 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 1.338889 $95.8800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 15 15 55.876799 $12851.6600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 737 912 520.043094 $26002.3800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 75 80 36.971290 $924.3000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1804 2258 2819.049426 $140952.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 127 139 311.663491 $7791.5900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 541 610 847.392974 $42369.6400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 40 48 54.076193 $1351.9100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 469 514 640.212154 $32010.5800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 17 18 15.277776 $381.9400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1281 1374 1531.022414 $76551.1600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 111 129 289.966668 $7249.1700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 30.088888 $2206.1200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 236 266 2570.626188 $64265.6600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 22.471429 $1123.5700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 10 11 32.630953 $1631.5500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4927 5452 31616.466770 $1580823.8200 $50.0000
INTR -T1013 INTERPRETER 148 169 648.428382 $32421.4100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3094 4850 20661.138913 $206611.4400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 688 756 4021.248875 $287278.1300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 101 111 596.853577 $34140.0100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 740 800 3812.291187 $272350.1400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 65 66 312.530953 $17864.2600 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 0.784476 $50.9900 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.389955 $44.4600 $114.0100
SENS -V5050 IN EAR MONAURAL HEARING AID 12 13 6.583562 $1501.0800 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
3 3 0.383562 $87.4400 $227.9600
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 7 7 1.995054 $909.7700 $456.0100
SENS -V5264 EARMOLD 35 38 27.988660 $503.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1187 1300 7148.220023 $510668.8900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 16.357142 $935.6300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 20 20 103.180955 $1432.1500 $13.8800
TRAV -TRAVS Travel by mile 1316 2082 142923.038713 $63600.7600 $0.4500
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Subtotal (Total Children Is Unduplicated) 6903 22229 221952.514700 $3735445.6900 $16.8300
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Total 26086 226023.577381 $3950504.7900 $17.4800
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Number of Children (Unduplicated) With at Least One Authorization 7723