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: 07-01-17 and 09-30-17 Date of Report: 11-04-17 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 27967 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 185 191 428.237301 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 19.676190 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 4.466667 $165.2700 $37.0000
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Subtotal (Total Children Is Unduplicated) 195 204 452.380158 $165.2700 $0.3700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 110 133 80.084375 $3884.0900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 4.144443 $212.8100 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 7 7 4.977778 $89.2000 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 246 250 226.749999 $4841.1100 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 7 4.799315 $60.5200 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 47 47 23.519376 $506.8500 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 17 17 8.432191 $69.6500 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 2.305556 $20.8900 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 20 23.146477 $585.8400 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 3.527778 $123.3700 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 13 5.241020 $404.2500 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $92.8400 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 3.904413 $72.4200 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 22 22 14.650001 $302.9600 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 9 4.881887 $219.6900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 6.324353 $727.3200 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 19 24 19.010197 $950.5200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 332 343 548.050389 $27402.5200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 6 6.015068 $451.1300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 58 73 77.869914 $5840.2500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 32 54 39.545818 $2965.9700 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 11 12 6.488508 $486.6400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 37 49 39.116515 $2933.7400 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 51 75 44.836854 $2488.4600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 464 464 627.408968 $47055.7700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 196 196 327.366329 $24552.5200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 118 118 139.042351 $10428.2000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 492 493 699.770071 $38837.2800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 302 312 399.479435 $29961.0100 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 11 11 36.012699 $1800.6400 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 9 9 2.266666 $115.7100 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 60 60 26.291314 $1342.1800 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 13 13 2.252131 $114.9700 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 17 17 8.908297 $454.7700 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 41 42 33.110199 $1690.2800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 217 234 126.071971 $6435.9800 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 4 4 0.454337 $23.1900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 42 44 12.165377 $621.0600 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 21 21 5.033790 $256.9800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 11 11 4.460198 $227.6900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 29 29 32.502034 $1659.2400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 201 215 96.658527 $4934.4100 $51.0500
SCREEN-T1023 SCREENING 32 34 27.994978 $1399.7500 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 2.400000 $36.0000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 4.327854 $220.9300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 9 9 2.793759 $142.6200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 424 458 313.523016 $16005.3800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 26 26 13.355154 $681.7800 $51.0500
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Subtotal (Total Children Is Unduplicated) 2569 4033 4143.271680 $244731.3600 $59.0700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 112 123 66.482341 $332411.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 6 6 3.244445 $162.2300 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 25 26 23.526288 $1176.3200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 9.123015 $653.3000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 26 27 10.691097 $2459.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 727 847 614.363398 $30718.3500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 75 82 47.142493 $1178.5700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1968 2453 3319.703344 $165985.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 136 150 202.396035 $5059.9000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 584 693 874.723365 $43736.1500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 43 50 47.025003 $1175.6300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 489 543 733.615666 $36680.8000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 25 34 32.161112 $804.0300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1420 1534 1874.578785 $93728.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 107 122 175.131748 $4378.2900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 10 11 33.587301 $2462.6100 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 10.000000 $250.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 246 312 2275.697606 $56892.4100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 16.857143 $842.8600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 10 10 35.249270 $1762.4600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5330 5971 37750.838204 $1887541.2700 $50.0000
INTR -T1013 INTERPRETER 148 185 640.795787 $32039.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3322 5178 23955.991943 $239559.8200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 749 836 4330.884956 $309398.4200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 107 117 626.061514 $35810.6800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 748 817 4223.365484 $301717.1500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 61 64 403.904760 $23087.1900 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 6 3.932419 $255.6200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 2.000000 $228.0000 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 9 9 3.152663 $718.8200 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
3 3 2.087671 $476.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
3 4 1.443835 $658.4200 $456.0200
SENS -V5264 EARMOLD 30 31 28.447186 $512.0500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1203 1343 7823.116498 $558883.3800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 35 35 183.473384 $2546.6100 $13.8800
TRAV -TRAVS Travel by mile 1338 2099 153551.555553 $68330.4500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7409 23730 243936.351312 $4244281.7600 $17.4000
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Total 27967 248532.003150 $4489178.3800 $18.0600
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Number of Children (Unduplicated) With at Least One Authorization 8176