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
Eligibility Filter: Program Patients
With the filters selected there were 39173 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 1 1 2.333333 $86.3300 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 245 253 492.103174 $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
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 256 267 518.579364 $251.6000 $0.4900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 144 169 97.151193 $4711.8300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 4.144443 $212.8100 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 9.122222 $163.4700 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 362 369 335.716667 $7167.5500 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 14 14 11.499315 $145.0100 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 62 62 31.894794 $687.3400 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 30 30 17.766132 $146.7500 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 4 4 3.305556 $29.9500 $9.0600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 35 35 34.585974 $875.3700 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 11 11 8.872222 $310.2600 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 20 21 10.694520 $824.8700 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 3.000000 $139.2600 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 20 21 13.699542 $254.1200 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 32 32 23.238890 $480.5800 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 18 18 10.823974 $487.0800 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 30 30 20.008752 $2301.0200 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 2.000000 $250.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 26 34 24.700608 $1235.0400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 458 475 718.842126 $35942.1000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 7 6.020547 $451.5500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 75 91 92.654159 $6949.0700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 39 64 44.367886 $3327.6200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 14 15 8.498097 $637.3600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 52 66 57.656013 $4324.2000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 63 90 57.730612 $3204.0700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 659 659 902.161008 $67662.2300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 268 268 434.458103 $32584.4300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 182 182 211.602619 $15870.2400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 674 675 926.741609 $51434.1900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 393 405 523.264363 $39244.8800 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.866667 $143.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 18 19 55.415080 $2770.7600 $50.0000
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 10 10 2.433333 $124.2200 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 85 85 31.381042 $1602.0300 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 18 18 3.967320 $202.5300 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 23 23 11.434705 $583.7500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 82 86 67.930747 $3467.8700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 349 373 206.661132 $10550.0500 $51.0500
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 5 5 0.487670 $24.8900 $51.0400
PSTF -97164 PT RE-EVAL EST PLAN CARE 71 73 22.870934 $1167.5900 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 27 27 7.463319 $381.0100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 18 18 8.615069 $439.8000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 42 42 40.569082 $2071.0600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 278 297 142.611376 $7280.3000 $51.0500
SCREEN-T1023 SCREENING 43 46 39.283867 $1964.1900 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 6 6 5.660350 $84.9000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.572298 $233.4100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 15 15 6.442541 $328.8900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 724 777 523.520034 $26725.7600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 52 52 26.977224 $1377.1800 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.333333 $16.6700 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3800 5854 5857.719069 $343594.4200 $58.6600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 162 178 100.734243 $503671.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 12 12 6.771158 $338.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 70 73 53.099649 $2654.9800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 8 8 9.714339 $695.6400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 51 52 36.208591 $8328.0200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1039 1217 852.710327 $42635.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 119 126 68.148527 $1703.7300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2578 3231 4830.926866 $241546.4700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 171 186 242.025399 $6050.6300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 863 1011 1391.658282 $69582.8700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 52 65 64.347227 $1608.6900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 678 752 1060.662855 $53033.1800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 36 34.444445 $861.1100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2002 2179 2785.701567 $139285.1300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 140 158 227.920635 $5698.0100 $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 330 423 2999.821419 $74995.4800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 91.285714 $4564.2900 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 11 11 36.582603 $1829.1300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7067 7925 50241.636546 $2512081.0200 $50.0000
INTR -T1013 INTERPRETER 160 197 683.867217 $34193.3600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4380 6918 32694.169426 $326941.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1206 1344 7204.507773 $514689.9900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 147 163 875.185325 $50060.5500 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 1186 1292 6755.893272 $482640.8200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 76 80 469.215474 $26820.3500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 9 10 6.157077 $400.2200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 2.054795 $234.2500 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 15 15 7.350684 $1675.9600 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
8 8 5.779148 $1317.6600 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
17 18 15.940107 $7268.7300 $456.0000
SENS -V5264 EARMOLD 70 72 73.282878 $1319.0900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2233 2495 14463.776044 $1033291.8900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 56 57 341.521005 $4740.3100 $13.8800
TRAV -TRAVS Travel by mile 1727 2721 189450.575109 $84305.5100 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 10402 33052 318227.263027 $6243777.0600 $19.6200
-------------------------------------------------------------------------------------------------------------------------------------
Total 39173 324603.561460 $6587623.0800 $20.2900
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 11543