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 15629 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 182 188 427.470635 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 6 7 19.676190 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 186 195 447.146825 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 97 117 71.355076 $3460.7200 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 49 50 43.733333 $933.7100 $21.3500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.216667 $4.6700 $21.5500
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.111111 $8.5700 $77.1200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 0.750000 $15.5100 $20.6800
EVAL -96111 DEVELOPMENTAL EVALUATION 18 22 15.010197 $750.5200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 332 343 548.050389 $27402.5200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 5.161112 $387.0900 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 21 21 6.633337 $497.5300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.483333 $36.2500 $74.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 14 14 7.361113 $552.1000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 24 24 8.444447 $468.6800 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 13.519177 $1013.9400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 5.000000 $375.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 7 7 9.576908 $718.2700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 15 15 23.510958 $1304.8600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 12.016437 $901.2400 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 2.700000 $135.0000 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 1 1 0.183333 $9.3600 $51.0400
OCTF -97168 OT RE-EVAL EST PLAN CARE 14 14 3.107307 $158.6300 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 2 2 1.438889 $73.4600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.071233 $3.6300 $51.0300
OCTH -97166 OT EVAL MODERATE COMPLEXITY 14 14 12.318265 $628.8400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 29 30 8.341172 $425.8200 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 1 1 0.087671 $4.4800 $51.0700
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 17 3.801374 $194.0800 $51.0600
PSTH -97001 EVAL BY LICENSED PT, INITIAL 4 4 0.311872 $15.9200 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.071233 $3.6300 $51.0300
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.090411 $55.6600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 19 16.445445 $839.5500 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.127778 $6.5200 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 88 94 57.134620 $2916.7400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 9 9 3.374962 $172.2900 $51.0500
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Subtotal (Total Children Is Unduplicated) 721 870 882.539160 $44524.8000 $50.4500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 27 31 19.543456 $97717.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 13 13 10.192954 $509.6500 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 1.197261 $275.3800 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 627 731 510.346301 $25517.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 32 36 19.651164 $491.2900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1943 2426 3294.902552 $164745.2000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 134 147 200.962701 $5024.0600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 580 689 870.778920 $43538.9300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 43 50 47.025003 $1175.6300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 466 518 712.622016 $35631.1100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 25 34 32.161112 $804.0300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1401 1512 1857.037514 $92851.9100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 106 121 174.131748 $4353.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 20 21 84.778570 $2119.4600 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 17.744444 $887.2200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 252 294 1692.226190 $84611.2800 $50.0000
INTR -T1013 INTERPRETER 146 182 632.081501 $31604.0800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3320 5176 23931.277657 $239312.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 101 111 597.080955 $42655.4400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 13 16 94.500001 $5405.3900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 105 112 499.703970 $35698.8100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 12 12 115.714288 $6614.2200 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.272146 $212.6900 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.049315 $11.2400 $227.9300
SENS -V5264 EARMOLD 2 2 1.382648 $24.8900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 197 214 1297.923007 $92723.6400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 28.928572 $401.5300 $13.8800
TRAV -TRAVS Travel by mile 1337 2098 153549.412696 $68329.4900 $0.4500
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Subtotal (Total Children Is Unduplicated) 5602 14564 190296.628662 $1083247.5100 $5.6900
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Total 15629 191626.314647 $1127772.3000 $5.8900
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Number of Children (Unduplicated) With at Least One Authorization 5877