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: 04-01-17 and 06-30-17 Date of Report: 08-05-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 27095 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 155 158 621.955989 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 11 60.444443 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 8 8 6.300000 $233.1000 $37.0000
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Subtotal (Total Children Is Unduplicated) 172 177 688.700432 $233.1000 $0.3400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 114 133 120.765929 $5857.1500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 14 3.755555 $192.8500 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 6 6 2.222451 $39.8300 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 234 236 189.377778 $4043.2200 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 1.741629 $21.9600 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 39 40 33.895348 $730.4500 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 1.856698 $15.3400 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 0.738889 $6.6900 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 10 1.881355 $47.6200 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 0.738889 $25.8400 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 19 19 7.094447 $547.2100 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 1.334247 $24.7500 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 17 18 7.142389 $147.7000 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 5 4.375397 $196.8900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 9.782094 $1124.9500 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 3 3 1.211111 $151.3900 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 18 27 24.211932 $1210.6100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 343 364 481.130773 $24056.5300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 5 4.699206 $352.4400 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 48 54 61.699771 $4627.4800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 32 52 34.026181 $2551.9800 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 5.655479 $424.1600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 34 38 39.446239 $2958.4600 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 55 76 56.007242 $3108.4100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 495 496 654.375225 $49078.2200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 215 215 358.083271 $26856.2800 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 137 137 178.191775 $13364.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 472 477 599.705722 $33283.6900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 250 254 318.323408 $23874.3000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 14 14 48.742858 $2437.1500 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 9 2.473745 $126.2900 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 26 27 7.477780 $381.7500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 95 95 50.938230 $2600.4000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 3.444445 $175.8400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 36 37 30.384779 $1551.1400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 157 161 130.176978 $6645.5400 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 13 13 2.046119 $104.4500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 25 26 6.967964 $355.7400 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 67 68 106.196762 $5421.3600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 5.233334 $267.1700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 20 20 13.118037 $669.6800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 111 120 52.147535 $2662.1500 $51.0500
SCREEN-T1023 SCREENING 36 37 31.677582 $1583.8900 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.511111 $22.6700 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 4.495891 $229.5100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 10 10 3.168493 $161.7500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 346 356 174.418907 $8904.0500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 32 32 15.555100 $794.0900 $51.0500
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Subtotal (Total Children Is Unduplicated) 2442 3767 3894.212747 $234043.7300 $60.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 124 130 94.105706 $470527.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 1.744444 $87.2200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 16 17 19.043673 $952.1900 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 4 4 2.783333 $199.3100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 20 20 6.695511 $1539.9900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 785 941 567.187543 $28359.5400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 81 91 45.112926 $1127.8200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1908 2378 2871.570634 $143578.5900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 135 152 228.911907 $5722.8000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 552 645 853.059521 $42652.9700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 33 45 34.157142 $853.9300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 498 550 712.896224 $35644.8200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 23 35 28.583332 $714.5800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1331 1426 1593.655345 $79682.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 97 106 195.927778 $4898.1900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 8 9 14.933333 $1094.9100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 255 335 3168.257146 $79206.3900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 51.428571 $2571.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 12 14 77.511907 $3875.6100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5116 5760 34655.493121 $1732773.7600 $50.0000
INTR -T1013 INTERPRETER 129 152 539.172070 $26958.5900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3147 4969 21433.115666 $214331.0100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 740 813 4083.829390 $291748.6700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 92 99 535.099996 $30607.7500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 822 907 4116.239685 $294064.0300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 54 63 265.053968 $15150.4800 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 4.480366 $291.2300 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.126027 $14.3600 $113.9800
SENS -V5050 IN EAR MONAURAL HEARING AID 5 5 3.250304 $741.0700 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
1 1 4.066667 $927.2100 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
6 6 5.370299 $2448.8600 $456.0000
SENS -V5264 EARMOLD 22 22 20.779375 $374.0300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1212 1361 7145.951527 $510506.6400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 12.571429 $719.0800 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 19 19 128.090475 $1777.9000 $13.8800
TRAV -TRAVS Travel by mile 1316 2064 121953.441892 $54269.2800 $0.4500
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Subtotal (Total Children Is Unduplicated) 7245 23151 205473.698233 $4080994.3800 $19.8600
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Total 27095 210056.611412 $4315271.2100 $20.5400
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Number of Children (Unduplicated) With at Least One Authorization 8043