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 14341 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 154 158 747.823811 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 8 10 71.571427 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 159 168 819.395238 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 107 125 84.397010 $4093.2500 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 15 15 10.655556 $227.5000 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.438356 $9.4500 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.044444 $0.3700 $8.2500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.044444 $1.1200 $25.2900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.894444 $68.9900 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.044444 $0.8200 $18.5300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 5.030517 $104.0300 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.205555 $9.2500 $44.9900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.183333 $21.0800 $114.9800
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 0.123288 $15.4100 $125.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 12 18 17.227471 $861.3800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 309 322 396.652139 $19832.6000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 3.183257 $238.7500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 24 25 10.611111 $795.8300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 17 17 4.833333 $362.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 37 38 14.349846 $796.4100 $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 2 2 0.286073 $14.3000 $49.9900
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 1.601674 $81.7600 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 11 11 3.594445 $183.5000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 7 7 3.600076 $183.7900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 3 0.602132 $30.7400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 27 31 36.799164 $1878.6100 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 0.580518 $29.6300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 8 10 3.472222 $177.2600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 7 7 2.759360 $140.8700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 1.089422 $55.6100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.353425 $18.0400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 14 14 25.057232 $1279.1800 $51.0500
SCREEN-T1023 SCREENING 1 1 0.133333 $6.6700 $49.9900
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 57 58 57.087008 $2914.3000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 6 6 8.502381 $434.0500 $51.0500
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Subtotal (Total Children Is Unduplicated) 646 802 760.566696 $39334.5000 $51.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 26 26 17.288431 $86441.5000 $4999.9600
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.088889 $4.4500 $50.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 9 2.938432 $146.9200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 2.927093 $673.2300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 624 746 420.119164 $21006.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 26 27 6.773252 $169.3500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1721 2153 2993.885362 $149694.2700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 126 132 238.099201 $5952.4800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 536 653 880.371421 $44018.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 38 46 42.780952 $1069.5200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 405 443 612.920107 $30646.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 28 22.938888 $573.4700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1151 1219 1547.364091 $77368.1500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 104 118 232.355551 $5808.8900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.100000 $7.3300 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 4 13.247620 $331.1900 $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 7 7 52.216666 $2610.8300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 179 193 1227.087295 $61354.4100 $50.0000
INTR -T1013 INTERPRETER 138 161 578.648799 $28932.4400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3281 4918 22269.944618 $222699.5400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 78 85 514.309708 $36742.2900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 11 14 69.357142 $3967.2400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 86 90 601.135711 $42945.1600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 9 45.176191 $2582.2700 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.052055 $3.3900 $65.0600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.632648 $144.2300 $227.9800
SENS -V5060 BEHIND EAR HEARING AID
1 1 1.000000 $228.0000 $228.0000
SENS -V5264 EARMOLD 2 2 0.632648 $11.3900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 151 167 1032.010051 $73726.8700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 49.571428 $688.0500 $13.8800
TRAV -TRAVS Travel by mile 1192 2105 131526.876373 $58529.4700 $0.4500
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Subtotal (Total Children Is Unduplicated) 5088 13371 165006.749787 $959271.9600 $5.8100
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Total 14341 166586.711721 $998606.4600 $5.9900
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Number of Children (Unduplicated) With at Least One Authorization 5367