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: 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 25535 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 156 160 749.579367 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 8 10 71.571427 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 4.600001 $170.2000 $37.0000
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Subtotal (Total Children Is Unduplicated) 167 176 825.750795 $170.2000 $0.2100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 114 134 88.031561 $4269.5300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 3.805555 $195.4100 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 3.488889 $62.5200 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 86 87 70.666666 $1508.7300 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 7 2.995509 $37.7700 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 53 53 44.415076 $957.1400 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 16 4.661870 $38.5100 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 2.205556 $19.9800 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 17 17 5.661870 $143.3000 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 3.488889 $122.0100 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 9 9 4.799999 $370.2200 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 3.000000 $139.2600 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 14 14 4.272981 $79.2600 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 24 24 12.380518 $256.0300 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 2.995510 $134.8000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 15 4.090030 $470.3600 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 0.123288 $15.4100 $125.0100
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 0.216667 $27.0900 $125.0200
EVAL -96111 DEVELOPMENTAL EVALUATION 17 27 21.408290 $1070.4300 $50.0000
EXIT -EXIT EXIT ASSESSMENT 311 324 397.854879 $19892.7300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 54 60 83.141046 $6235.5800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 43 68 46.475950 $3485.7100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 5.021916 $376.6500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 46 63 44.881736 $3366.1300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 76 110 76.446271 $4242.7700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 515 515 597.451630 $44809.0100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 253 254 351.866412 $26390.0700 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 130 130 134.827980 $10112.1100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 474 475 532.920530 $29577.1100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 211 217 237.745200 $17830.9100 $75.0000
NURS -T1001 NURSING ASSESSMENT 2 2 0.286073 $14.3000 $49.9900
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 10 18.794443 $939.7300 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 18 18 6.672680 $340.6500 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 40 41 13.367460 $682.4100 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 63 66 29.913849 $1527.0900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 13 14 5.167277 $263.7900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 25 26 16.642389 $849.6000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 175 210 132.140613 $6745.7600 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 15 16 3.030594 $154.7100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 31 35 9.780060 $499.2700 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 47 47 35.411414 $1807.7600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 15 15 9.074127 $463.2400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 26 27 14.115677 $720.6000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 162 195 116.599864 $5952.4600 $51.0500
SCREEN-T1023 SCREENING 29 30 19.969102 $998.4500 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 2.607611 $39.1200 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 3.457610 $176.5100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 1.347946 $68.8100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 312 330 218.153753 $11136.7600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 28 28 19.135487 $976.8700 $51.0500
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Subtotal (Total Children Is Unduplicated) 2269 3787 3467.010303 $210594.4100 $60.7400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 116 124 55.039341 $275195.0000 $4999.9700
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 7 7 4.177777 $208.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 16 16 6.588433 $329.4300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 6 6 7.676985 $549.7500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 24 24 10.560959 $2429.0100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 703 838 507.786859 $25389.5200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 66 70 30.360179 $759.0200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1749 2186 3032.081393 $151604.0900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 127 133 239.099201 $5977.4800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 544 661 885.688088 $44284.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 38 46 42.780952 $1069.5200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 421 459 628.976816 $31448.8500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 28 22.938888 $573.4700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1176 1245 1578.570438 $78928.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 105 119 234.355551 $5858.8900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 29.304764 $2148.6400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 178 207 2190.642854 $54766.0800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 3.900000 $195.0000 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 11 11 54.856392 $2742.8200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4947 5366 33030.571423 $1651529.5400 $50.0000
INTR -T1013 INTERPRETER 138 161 578.648799 $28932.4400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3282 4924 22289.535093 $222895.4400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 637 685 3754.894495 $268249.7100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 114 131 706.538087 $40414.0100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 662 715 3841.639188 $274446.8500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 45 45 208.711903 $11929.9800 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.273973 $17.8100 $65.0100
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 1.252055 $142.7400 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 8 10 1.844977 $420.6600 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
3 3 2.123288 $484.1100 $228.0000
SENS -V5140 BEHIND THE EAR BINAURAL HEARING AI 3 3 1.839422 $838.7700 $455.9900
SENS -V5264 EARMOLD 24 26 9.772678 $175.9100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1067 1159 6578.843387 $469992.8700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 17.428572 $996.9200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 31 33 211.889693 $2941.0300 $13.8800
TRAV -TRAVS Travel by mile 1193 2113 131902.876372 $58696.7900 $0.4500
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Subtotal (Total Children Is Unduplicated) 6713 21572 212704.069275 $3717563.8500 $17.4800
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Total 25535 216996.830373 $3928328.4700 $18.1000
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Number of Children (Unduplicated) With at Least One Authorization 7194