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
Eligibility Filter: Program Patients
With the filters selected there were 38220 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 2 2 1.107143 $40.9600 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 214 220 295.692855 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 8 9 17.702380 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 4.244444 $157.0400 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 229 236 318.746822 $198.0100 $0.6200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 115 137 97.931590 $4749.6500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 20 20 11.017602 $565.7600 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 7 9 4.668874 $83.6700 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 304 307 291.955555 $6233.2500 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 14 15 10.171766 $128.2700 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 50 51 27.009205 $582.0400 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 30 31 21.664002 $178.9400 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.500000 $4.5300 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 32 33 33.528288 $848.6000 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 10 11 10.133333 $354.3600 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 16 16 7.844445 $605.0500 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.081278 $96.6100 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 13 14 4.905479 $91.0000 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 29 29 24.960044 $516.1700 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 17 18 16.806565 $756.2900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 20 22 22.745912 $2615.7900 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 0.172222 $21.5300 $124.9800
EVAL -96111 DEVELOPMENTAL EVALUATION 23 33 30.977001 $1548.8600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 471 498 679.330876 $33966.5300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 7 4.960241 $372.0200 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 62 70 95.816363 $7186.2300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 30 45 35.526179 $2664.4700 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 13 10.369330 $777.7000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 63 82 90.923875 $6819.2800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 64 90 65.217428 $3619.5700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 710 710 926.826675 $69512.1200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 295 296 485.426908 $36407.0600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 190 190 239.782187 $17983.6800 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 687 692 971.446815 $53915.3100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 351 357 502.198352 $37664.9500 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.566667 $28.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 20 22 60.729365 $3036.4700 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.344444 $17.5800 $51.0400
OCTF -97168 OT RE-EVAL EST PLAN CARE 72 74 21.454337 $1095.2500 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 0.087672 $4.4700 $51.0100
OCTH -97165 OT EVAL LOW COMPLEXITY 22 22 22.010904 $1123.6600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 82 86 62.528232 $3192.0600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 390 407 222.981736 $11383.2900 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 2 2 0.511111 $26.0900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 73 75 35.883436 $1831.8800 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.032877 $1.6800 $51.0800
PSTH -97161 PT EVAL LOW COMPLEXITY 14 15 11.907077 $607.8500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 54 54 38.367743 $1958.6800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 291 310 125.459822 $6404.7800 $51.0500
SCREEN-T1023 SCREENING 52 53 46.665100 $2333.2500 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 4 1.812481 $27.1900 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 3.112177 $158.8800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 9 9 6.788411 $346.5500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 699 736 499.136770 $25480.9200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 74 77 67.754599 $3458.8700 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.213699 $10.6900 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3600 5763 5957.247050 $353647.6800 $59.3600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 144 159 116.345445 $581727.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 9 10 7.894216 $394.7100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 59 62 48.165168 $2408.2700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 0.908067 $65.0300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 36 38 18.867962 $4339.6600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1115 1294 785.154868 $39258.0200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 125 133 80.835207 $2020.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2567 3155 4355.724064 $217786.0500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 191 201 255.220588 $6380.5100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 830 971 1334.545246 $66727.3000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 60 87 71.914288 $1797.8600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 657 749 987.065318 $49353.3800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 36 55 43.050004 $1076.2600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1905 2019 2490.703589 $124535.0700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 158 162 202.087670 $5052.1900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 13 31.425395 $2304.1100 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 314 421 2662.342805 $66558.7400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 150.428570 $7521.4400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 16 19 61.975180 $3098.7600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6969 7636 47554.745181 $2377738.5100 $50.0000
INTR -T1013 INTERPRETER 149 193 659.652200 $32982.5900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4337 6650 30335.913442 $303359.2300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1168 1285 6629.962727 $473644.7900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 145 148 783.620236 $44823.1200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1146 1266 6681.891651 $477354.5100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 85 96 394.466267 $22547.7100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 9 1.553044 $100.9500 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.301370 $34.3500 $113.9700
SENS -V5050 IN EAR MONAURAL HEARING AID 9 9 5.877246 $1340.0200 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
2 2 2.933333 $668.7900 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
12 13 17.518591 $7988.4800 $456.0000
SENS -V5264 EARMOLD 50 53 41.701695 $750.6300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2210 2444 14119.071378 $1008666.8400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 8 55.285714 $3162.3400 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 71 73 531.933328 $7383.2400 $13.8800
TRAV -TRAVS Travel by mile 1546 2779 171479.319635 $76308.3100 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 10110 32221 293000.400688 $6021259.6300 $20.5500
-------------------------------------------------------------------------------------------------------------------------------------
Total 38220 299276.394560 $6375105.3200 $21.3000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 10771