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
Eligibility Filter: Program Patients
With the filters selected there were 38077 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.107143 $3.9600 $36.9900
SCONLY-SCONLY *SERVICE COORDINATION ONLY 190 195 651.955984 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 12 12 65.873014 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 12 12 11.155556 $412.7600 $37.0000
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Subtotal (Total Children Is Unduplicated) 213 220 729.091697 $416.7200 $0.5700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 153 180 204.691123 $9927.5300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 15 16 6.988888 $358.8800 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 15 16 13.208165 $236.6900 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 354 357 290.363490 $6199.2600 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 16 16 11.071788 $139.6200 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 63 64 45.837965 $987.8100 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 25 25 12.882062 $106.4100 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 8 8 6.346825 $57.5000 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 26 26 14.681148 $371.5800 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 10 10 9.346825 $326.8600 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 38 38 14.503351 $1118.6600 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 1.202740 $55.8300 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 17 17 8.623897 $159.9800 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 31 32 19.364785 $400.4600 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 16 9.347848 $420.6500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 25 25 16.372277 $1882.8100 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 4 4 1.638889 $204.8600 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 21 31 30.299603 $1514.9900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 486 515 681.252875 $34062.6600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 7 4.945781 $370.9400 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 65 71 86.250456 $6468.7800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 41 69 41.626183 $3122.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 8 6.658219 $499.3700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 52 59 63.396240 $4754.7200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 71 97 70.008385 $3885.4700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 709 710 923.021197 $69226.7200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 295 296 481.585812 $36118.9800 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 189 189 237.782187 $17833.6800 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 682 687 825.309829 $45804.7100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 348 354 442.055887 $33154.2600 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 24 24 70.329366 $3516.4700 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 18 18 4.143228 $211.5200 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 40 42 12.010658 $613.1600 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 138 138 64.221640 $3278.5200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 12 12 8.000305 $408.4200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 65 66 49.738280 $2539.1400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 248 254 174.378731 $8902.0500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 17 17 2.996119 $152.9500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 45 46 15.993762 $816.5000 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 97 98 114.384660 $5839.3500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 6.677778 $340.9000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 39 40 24.139574 $1232.3300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 163 181 75.475236 $3853.0300 $51.0500
SCREEN-T1023 SCREENING 53 54 43.927048 $2196.3600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 1.813699 $27.2100 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 5.534247 $282.5200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 14 14 5.651826 $288.5200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 628 656 338.545792 $17282.7500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 54 54 24.012558 $1225.8500 $51.0500
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Subtotal (Total Children Is Unduplicated) 3668 5680 5623.205894 $332808.5200 $59.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 187 200 205.019198 $1025094.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 14 14 7.572222 $378.6100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 47 49 39.056156 $1952.8100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 7 7 4.988889 $357.2600 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 38 38 15.889044 $3654.5200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1091 1314 799.083415 $39954.4100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 112 123 68.669757 $1716.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2543 3180 4193.382151 $209669.2200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 174 195 278.557543 $6963.9400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 824 951 1281.698007 $64084.8800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 45 60 51.807141 $1295.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 677 740 991.533929 $49576.7300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 40 33.022220 $825.5500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1908 2038 2462.877975 $123143.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 128 139 238.602752 $5965.0600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 11 15.988889 $1172.3100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 327 430 4096.485720 $102412.1100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 158.571429 $7928.5700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 14 16 82.189685 $4109.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6736 7602 45729.824896 $2286490.1300 $50.0000
INTR -T1013 INTERPRETER 152 178 618.162678 $30908.1200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4121 6605 28863.355591 $288633.3800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1198 1313 6644.989313 $474717.8100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 119 129 680.235709 $38909.5100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1244 1369 6513.164691 $465300.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 74 85 372.927779 $21316.5400 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 5.122223 $332.9500 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.339726 $38.7300 $113.9900
SENS -V5050 IN EAR MONAURAL HEARING AID 14 14 10.190487 $2323.4100 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
2 2 4.214612 $960.9300 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
14 14 10.620527 $4842.9000 $455.9900
SENS -V5264 EARMOLD 56 57 44.523732 $801.4200 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2193 2470 13571.670588 $969559.7400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 16.000000 $915.2000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 39 39 242.557140 $3366.7000 $13.8800
TRAV -TRAVS Travel by mile 1707 2739 161906.817764 $72048.5400 $0.4500
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Subtotal (Total Children Is Unduplicated) 10123 32177 280259.713578 $6311721.5300 $22.5200
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Total 38077 286612.011169 $6644946.7700 $23.1800
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Number of Children (Unduplicated) With at Least One Authorization 11292