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 15006 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 154 157 619.122656 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 11 11 60.444443 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 163 168 679.567099 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 103 120 113.336628 $5496.8300 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.183562 $3.2900 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 25 25 23.394445 $499.4700 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.183562 $2.3200 $12.6100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.183562 $1.5200 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.208219 $5.2700 $25.3100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 11 4.870167 $100.7100 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.472222 $21.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.740715 $85.1800 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 14 20 20.173578 $1008.6900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 339 360 477.396222 $23869.8100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 8.488889 $636.6700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 19 20 6.166669 $462.5200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.294444 $172.0800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 9 8.126984 $609.5200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 21 21 9.626909 $534.3000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 20.124655 $1509.3600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 13 13 26.000000 $1950.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 13 13 17.521916 $972.4700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 11.093150 $831.9900 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 3 3 1.538889 $78.5600 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 9 10 1.988889 $101.5300 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 12 12 3.400001 $173.5800 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.305556 $15.6000 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.172222 $59.8400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 22 12.492065 $637.7300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 5 0.761112 $38.8600 $51.0600
PSTH -97001 EVAL BY LICENSED PT, INITIAL 8 9 5.444368 $277.9400 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.216667 $11.0600 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.112329 $107.8300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 11 11 3.218265 $164.2900 $51.0500
SCREEN-T1023 SCREENING 1 1 0.900000 $45.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.344444 $17.5800 $51.0400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 57 61 32.282594 $1648.0200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 4 4 1.416666 $72.3200 $51.0500
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Subtotal (Total Children Is Unduplicated) 659 810 823.747232 $42602.3500 $51.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 30 31 11.848476 $59241.5000 $4999.9300
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.522222 $26.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 10 12.424625 $621.2300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.033333 $73.9900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 2.194445 $504.7400 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 670 801 442.300438 $22115.2100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 29 35 11.814245 $295.3600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1872 2340 2829.807934 $141490.4600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 132 149 226.911114 $5672.7800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 534 626 833.703964 $41685.1900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 33 45 34.157142 $853.9300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 477 528 690.841668 $34542.0900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 34 28.572221 $714.3000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1293 1387 1556.815661 $77840.7000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 96 105 195.661111 $4891.5200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.200000 $87.9800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 8 25.680954 $642.0300 $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 8 10 69.730954 $3486.5600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 232 253 1613.868259 $80693.4100 $50.0000
INTR -T1013 INTERPRETER 127 150 526.875245 $26343.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3146 4965 21423.229953 $214232.1500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 98 104 603.313464 $43100.6800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 10 66.700000 $3815.2400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 121 128 628.135712 $44874.0000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 10 50.776191 $2902.3700 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 4.315982 $280.5400 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.126027 $14.3600 $113.9800
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 2.740715 $624.8800 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
3 3 0.900457 $410.5800 $455.9700
SENS -V5264 EARMOLD 7 7 5.104947 $91.8900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 189 204 1211.280957 $86533.9000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 9 9 61.142856 $848.6700 $13.8800
TRAV -TRAVS Travel by mile 1315 2060 121933.560941 $54260.4400 $0.4500
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Subtotal (Total Children Is Unduplicated) 5348 14028 155158.720784 $956383.9300 $6.1600
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Total 15006 156662.035115 $998986.2800 $6.3800
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Number of Children (Unduplicated) With at Least One Authorization 5610