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 14987 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 163 166 240.567457 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 7 7 17.457936 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 170 173 258.025393 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 70 84 47.679459 $2312.4400 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 32 34 33.966667 $725.1900 $21.3500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.450000 $34.7100 $77.1300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.522222 $10.8000 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.450000 $20.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.450000 $51.7500 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 18 24 22.867414 $1143.3800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 340 361 494.153057 $24707.6400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.127778 $9.5900 $75.0100
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 7.594445 $569.5900 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 12 12 5.700000 $427.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 3.183333 $238.7500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 15 15 9.811112 $735.8400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 23 23 8.833257 $490.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 19 19 20.042463 $1503.2000 $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 8 8 11.010958 $825.8300 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 2.833333 $141.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 1.688889 $86.2200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.197260 $10.0700 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 6.266666 $319.9100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 26 26 17.958229 $916.7700 $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 5 5 1.100001 $56.1600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.244444 $12.4800 $51.0400
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 3.283333 $167.6100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 17 17 13.005567 $663.9400 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.438889 $22.4100 $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 54 58 39.197583 $2001.0200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 8 8 10.445292 $533.2300 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.213699 $10.6900 $50.0000
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Subtotal (Total Children Is Unduplicated) 633 766 813.315044 $42040.7300 $51.6900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 16 9.453880 $47269.0000 $4999.9600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 12 12 4.610807 $230.5400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 1.455023 $334.6700 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 681 776 417.058109 $20853.1200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 34 37 20.197580 $504.9500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1921 2381 3059.848670 $152992.3000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 148 154 182.092814 $4552.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 572 671 891.136513 $44556.8500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 47 71 55.877781 $1396.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 461 530 657.457372 $32872.9200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 29 47 36.794448 $919.8700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1345 1422 1624.520182 $81225.9300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 120 124 142.489682 $3562.2400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 8.365080 $613.3400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 22 23 86.471426 $2161.8000 $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 9 11 46.666667 $2333.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 189 197 1266.822222 $63341.1500 $50.0000
INTR -T1013 INTERPRETER 123 160 547.621912 $27381.0700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3279 4978 22430.770733 $224307.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 72 73 418.404760 $29890.8500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 10 11 76.264286 $4362.3200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 75 80 416.539681 $29757.5900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 9 10 72.285713 $4131.8600 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.185236 $12.0400 $64.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.450000 $205.2000 $456.0000
SENS -V5264 EARMOLD 1 1 0.450000 $8.1000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 152 161 1061.916656 $75863.4000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 4 4 76.071428 $1055.8700 $13.8800
TRAV -TRAVS Travel by mile 1164 2087 128645.561406 $57247.2800 $0.4500
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Subtotal (Total Children Is Unduplicated) 5300 14048 162309.268638 $916516.0700 $5.6500
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Total 14987 163380.609075 $958556.8000 $5.8700
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Number of Children (Unduplicated) With at Least One Authorization 5561