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: 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 26627 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 172 178 356.388093 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 5 7.466667 $276.2700 $37.0000
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Subtotal (Total Children Is Unduplicated) 176 183 363.854760 $276.2700 $0.7600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 118 142 72.819442 $3531.7600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 6 6 2.833333 $145.4900 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 2.144444 $38.4300 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 257 260 268.488889 $5732.2400 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 7 7 4.380518 $55.2400 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 35 35 20.597618 $443.8800 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 18 18 7.180974 $59.3100 $8.2600
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.022222 $0.2000 $9.0500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 21 21 9.558752 $241.9300 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 2.022222 $70.7200 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 1.883333 $145.2600 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 4.571429 $212.2000 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 5.092085 $94.4500 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 3.411111 $70.5400 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 9 2.621614 $117.9700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 3.848707 $442.5900 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 3.571429 $446.4300 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 19 24 16.278690 $813.9400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 372 392 516.827846 $25841.4100 $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 47 52 43.442082 $3258.1700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 17 19 21.673591 $1625.5100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 4.120700 $309.0500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 28 33 26.498554 $1987.3900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 31 37 28.313336 $1571.4000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 465 465 627.650064 $47073.8500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 195 195 324.223472 $24316.8000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 118 118 139.072336 $10430.4500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 488 488 694.526235 $38546.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 299 309 398.731489 $29904.9200 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 8 8 18.346031 $917.3100 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 42 44 10.626192 $542.4800 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 15 15 13.986377 $714.0000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 60 61 38.633487 $1972.2400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 250 264 133.719609 $6826.4200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 39 39 24.972048 $1274.8200 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.087671 $4.4800 $51.0700
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 1.674353 $85.4800 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 20 20 19.143976 $977.3100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 210 227 78.064284 $3985.1900 $51.0500
SCREEN-T1023 SCREENING 28 30 25.394521 $1269.7300 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 2.933333 $44.0000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 39.327854 $2007.6800 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 1.619254 $82.6600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 405 444 244.037634 $12458.1700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 55 56 17.962785 $917.0100 $51.0500
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Subtotal (Total Children Is Unduplicated) 2477 3923 3932.950994 $232057.8400 $59.0000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 113 130 85.887044 $429436.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.000000 $100.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 27 27 31.723378 $1586.1800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 1.927778 $138.0500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 21 21 11.333258 $2606.6800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 727 834 561.732339 $28086.8500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 76 79 43.311938 $1082.8100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1913 2345 2981.728627 $149086.3800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 116 131 131.711109 $3292.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 589 686 862.381716 $43119.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 49 71 59.311107 $1482.7700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 455 508 591.740775 $29587.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 36 32.661112 $816.5300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1342 1413 1644.145658 $82207.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 102 112 129.569052 $3239.2400 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 8 30.533333 $2238.7000 $73.3200
DSTT -DSTT DIRECT SERVICE COORDINATOR TRAVEL 1 3 3.666667 $0.0000 $0.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 27.428571 $685.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 255 311 3240.857160 $81021.3600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 9.428571 $471.4300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 7 32.700000 $1635.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5063 5589 34380.130875 $1719005.5600 $50.0000
INTR -T1013 INTERPRETER 135 176 564.712941 $28235.6600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3135 4700 22104.043294 $221040.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 726 804 4252.278383 $303782.7700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 127 132 781.911900 $44725.3600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 740 804 4093.841948 $292463.9800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 62 68 337.952381 $19317.3500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.197260 $12.8200 $65.0100
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 1.288889 $146.9300 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 6 6 2.501370 $570.2700 $227.9800
SENS -V5060 BEHIND EAR HEARING AID
2 2 1.164384 $265.4800 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
4 4 1.427702 $651.0800 $456.0300
SENS -V5264 EARMOLD 24 24 15.271843 $274.8900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1212 1349 7647.555055 $546341.1700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.010959 $0.6300 $57.4100
SPL -92508 GROUP SPL SESSION PER CHILD 27 27 133.771428 $1856.7500 $13.8800
TRAV -TRAVS Travel by mile 1167 2102 156296.495225 $69551.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7013 22521 241130.335030 $4110163.2300 $17.0500
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Total 26627 245427.140784 $4342497.3300 $17.6900
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Number of Children (Unduplicated) With at Least One Authorization 7432