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 14606 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 187 192 379.074868 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 8 8 50.221430 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 193 200 429.296298 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 88 106 48.409364 $2347.8600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.161111 $8.2700 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 3.785714 $67.8400 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 35 35 34.702380 $740.8900 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 3.785714 $47.7400 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 3.785714 $81.5800 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 3.785714 $31.2700 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 3.785714 $34.3000 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 3.785714 $95.8200 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 3.785714 $132.3900 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 5.002381 $385.8400 $77.1300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 15 15 12.491270 $258.3200 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 0.123288 $15.4100 $125.0100
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 15 21 19.277471 $963.8800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 291 306 487.057706 $24352.8800 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 3.077702 $230.8400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 18 19 9.544444 $715.8300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 0.388889 $29.1700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 22 23 10.855402 $602.4700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 17 17 15.595435 $1169.6600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 6.005479 $450.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 8 8 12.009589 $900.7200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 17 17 24.015070 $1332.8300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 6 7.504110 $562.8100 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.002740 $0.1400 $49.2700
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 5 5 0.892770 $45.5700 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 4 4 1.666667 $85.0900 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 23 23 14.098368 $719.7100 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.084932 $4.3300 $51.0300
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 5.664242 $289.1600 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 6 6 5.200197 $265.4700 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.938889 $47.9300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 16 16 4.023212 $205.3900 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.427778 $21.8400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 2.185008 $111.5500 $51.0500
SCREEN-T1023 SCREENING 3 3 0.983333 $49.1700 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 61 61 48.308851 $2466.1700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 4 4 9.285714 $474.0400 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.211111 $10.5600 $50.0000
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Subtotal (Total Children Is Unduplicated) 617 745 819.694901 $40640.1200 $49.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 27 33 11.703957 $58519.0000 $4999.9300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.511111 $25.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 19 19 199.022071 $9951.1100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.005556 $0.4000 $72.1700
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 0.435921 $100.2600 $229.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 653 812 428.852382 $21442.8300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 35 36 13.923251 $348.0900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1759 2208 2743.489903 $137174.3700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 127 139 311.663491 $7791.5900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 523 592 803.519164 $40175.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 40 48 54.076193 $1351.9100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 441 484 579.273698 $28963.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 17 18 15.277776 $381.9400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1243 1334 1459.227176 $72961.3800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 110 128 287.966668 $7199.1700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 16.652382 $416.3100 $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 9 10 27.416667 $1370.8400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 243 268 1363.238097 $68161.9000 $50.0000
INTR -T1013 INTERPRETER 146 167 636.999811 $31849.9800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3093 4839 20615.716690 $206157.2200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 92 100 561.558921 $40117.7700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 18 19 112.607143 $6441.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 98 103 464.866667 $33210.1000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 9 58.000001 $3315.2700 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.428311 $27.8400 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
1 1 0.098630 $22.4800 $227.9300
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 3 3 1.316667 $600.4200 $456.0100
SENS -V5264 EARMOLD 3 3 2.388889 $43.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 192 203 1221.359587 $87253.9300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 3.785714 $52.5500 $13.8800
TRAV -TRAVS Travel by mile 1314 2070 142407.324428 $63371.2700 $0.4500
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Subtotal (Total Children Is Unduplicated) 5191 13661 174426.178352 $930150.7500 $5.3300
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Total 14606 175675.169551 $970790.8700 $5.5300
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Number of Children (Unduplicated) With at Least One Authorization 5470