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: 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 27121 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 165 168 242.989679 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 7 7 17.457936 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 4.244444 $157.0400 $37.0000
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Subtotal (Total Children Is Unduplicated) 177 180 264.692059 $157.0400 $0.5900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 80 98 55.675198 $2700.2200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 14 14 6.315079 $324.2800 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 3 1.366667 $24.4900 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 203 205 197.338887 $4213.1800 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 3.496347 $44.0900 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 37 37 19.370698 $417.4300 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 7.827853 $64.6600 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 21.542139 $545.2300 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 5.000000 $174.8500 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 8 8 3.222223 $248.5400 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 5 5 1.279452 $23.7300 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 15 15 13.799999 $285.3800 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 12.657936 $569.6100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 13.441498 $1545.7700 $115.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 0.172222 $21.5300 $124.9800
EVAL -96111 DEVELOPMENTAL EVALUATION 21 30 26.889330 $1344.4800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 343 364 497.775279 $24888.7500 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 6 4.954762 $371.6100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 45 52 70.728996 $5304.6800 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 23 34 28.792845 $2159.4600 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 8 11 9.366590 $702.5000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 44 58 66.001653 $4950.1100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 51 75 53.899620 $2991.4300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 496 496 658.180703 $49363.6200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 216 216 363.924367 $27294.3500 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 138 138 180.191775 $13514.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 476 481 745.755037 $41389.4300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 252 256 378.378202 $28378.4100 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 11 23.011905 $1150.5900 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 46 48 13.224125 $675.1000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.087672 $4.4700 $51.0100
OCTH -97165 OT EVAL LOW COMPLEXITY 17 17 10.478767 $534.9400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 46 48 34.544671 $1763.5000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 245 256 147.793964 $7544.9300 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.166667 $8.5100 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 43 44 16.656743 $850.3500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.032877 $1.6800 $51.0800
PSTH -97161 PT EVAL LOW COMPLEXITY 9 9 7.314307 $373.3900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 27 27 24.569570 $1254.2800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 191 199 82.537414 $4213.5700 $51.0500
SCREEN-T1023 SCREENING 38 39 33.435877 $1671.7900 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 1.511111 $22.6700 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 2.618265 $133.6600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 7 7 5.488411 $280.1800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 361 377 248.407334 $12681.1600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 40 42 39.269210 $2004.6900 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.213699 $10.6900 $50.0000
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Subtotal (Total Children Is Unduplicated) 2371 3786 4139.274613 $249064.6800 $60.1700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 85 95 57.209372 $286046.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.888889 $44.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 21 21 12.221918 $611.1000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.483333 $34.6100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 20 20 10.426865 $2398.2100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 800 921 544.502474 $27225.3100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 91 98 57.196261 $1429.9100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1948 2409 3078.069304 $153903.3300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 151 158 184.921384 $4623.0400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 578 677 894.536514 $44726.8600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 47 71 55.877781 $1396.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 480 551 675.881183 $33794.1200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 30 48 36.805559 $920.1500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1366 1443 1637.831291 $81891.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 120 124 142.489682 $3562.2400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 10 21.263491 $1559.0400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 235 318 2065.952348 $51648.9300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 62.571428 $3128.5800 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 14 17 54.291847 $2714.6000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5302 5777 36057.189273 $1802860.4300 $50.0000
INTR -T1013 INTERPRETER 125 163 549.204452 $27460.2000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3279 4979 22432.670733 $224326.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 737 807 4136.912727 $295541.2000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 107 109 560.496426 $32060.4200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 737 816 4253.006332 $303834.9300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 63 71 290.544838 $16607.5500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 0.470168 $30.5600 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 1.638357 $373.5600 $228.0100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
4 4 11.991270 $5468.0300 $456.0000
SENS -V5264 EARMOLD 21 21 22.392943 $403.0700 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1167 1288 7399.699970 $528634.7900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 32.000000 $1830.4000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 34 35 220.909522 $3066.2300 $13.8800
TRAV -TRAVS Travel by mile 1164 2089 128658.747120 $57253.1500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7147 23155 214221.295055 $4001410.6400 $18.6800
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Total 27121 218625.261727 $4250632.3600 $19.4400
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Number of Children (Unduplicated) With at Least One Authorization 7612