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 23117 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 241 248 484.622223 $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) 246 256 506.631746 $86.3300 $0.1700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 119 141 85.156293 $4130.0900 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.133333 $20.3100 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 66 67 57.505556 $1227.7400 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.055555 $25.9200 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 1.350000 $29.0900 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 3.055555 $25.2400 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 3.055555 $77.3300 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.133333 $39.6300 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 6 2.416666 $186.3900 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 4.166666 $77.2900 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 4.950000 $102.3700 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 1.159818 $52.2000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 5.137595 $590.8200 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 22 27 19.385159 $969.2600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 451 467 711.886571 $35594.3300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 18 7.419331 $556.4600 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 25 25 7.605559 $570.4400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 2.492922 $186.9700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 19 19 12.882802 $966.2300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 29 8.960504 $497.3200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 54 54 52.628763 $3947.1800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 21 21 23.042463 $1728.2000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 35 35 33.593344 $2519.5100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 95 95 79.409592 $4407.2200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 45 45 48.191775 $3614.4000 $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 2 2 0.350000 $17.8700 $51.0500
OCTF -97168 OT RE-EVAL EST PLAN CARE 25 25 5.223975 $266.7000 $51.0500
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 4 4 2.477778 $126.4900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 0.241096 $12.3000 $51.0300
OCTH -97166 OT EVAL MODERATE COMPLEXITY 31 31 26.773821 $1366.8000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 71 73 38.568840 $1968.9400 $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 34 36 12.295820 $627.7300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 6 6 1.339650 $68.3900 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 0.534627 $27.2900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 4.595814 $234.6200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 42 43 31.623591 $1614.3800 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 3.033333 $45.5000 $15.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 2.511111 $128.1900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 200 210 145.855423 $7445.9500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 21 21 10.274202 $524.5000 $51.0500
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Subtotal (Total Children Is Unduplicated) 1253 1559 1470.266941 $76932.4600 $52.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 51 57 33.976256 $169882.0000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 20 20 16.727885 $836.3900 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.216438 $15.5000 $71.6000
AUDE -V5160 DISPENSING FEE BINAURAL 14 14 15.826626 $3640.1200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 873 1027 672.399645 $33620.2400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 47 51 22.905427 $572.6500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2540 3191 4800.676074 $240033.9300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 169 183 240.592065 $6014.8000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 851 998 1384.036059 $69201.7500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 52 65 64.347227 $1608.6900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 643 713 1032.252539 $51612.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 36 34.444445 $861.1100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1958 2132 2758.532519 $137926.6800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 137 155 225.720635 $5643.0100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 61 78 331.330952 $8283.2700 $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 1353 1530 9634.091996 $481704.5200 $50.0000
INTR -T1013 INTERPRETER 158 194 675.152931 $33757.6500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4378 6914 32660.664664 $326606.5200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 257 281 1599.547627 $114271.6400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 24 29 154.407144 $8832.0700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 252 270 1386.367466 $99042.0000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 18 18 130.738098 $7472.9800 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 5.272146 $342.6900 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 2.482648 $566.0300 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
1 1 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
3 3 4.544444 $2072.2500 $456.0000
SENS -V5264 EARMOLD 12 12 20.893758 $376.0800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 529 580 3425.498410 $244717.5500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 17 17 112.619050 $1563.1500 $13.8800
TRAV -TRAVS Travel by mile 1726 2720 189448.432252 $84304.5600 $0.4500
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Subtotal (Total Children Is Unduplicated) 7934 21302 250915.441870 $2136775.6900 $8.5200
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Total 23117 252892.340557 $2213794.4900 $8.7500
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Number of Children (Unduplicated) With at Least One Authorization 8406