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 14640 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 170 176 353.165871 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 170 176 353.165871 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 107 129 65.768909 $3189.8100 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 51 52 51.877778 $1107.5900 $21.3500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.877778 $7.2500 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.877778 $22.2200 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.877778 $67.7000 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.877778 $16.2800 $18.5500
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.366667 $16.5000 $45.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 3.571429 $446.4300 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 18 22 12.278690 $613.9400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 372 392 516.827846 $25841.4100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 4.011111 $300.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 0.638889 $47.9200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 3 2.733333 $205.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 2.794444 $155.0900 $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 14 14 22.510958 $1249.3600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 12.016437 $901.2400 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 9 9 2.027780 $103.5300 $51.0600
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.180822 $60.2800 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 6.384018 $325.9000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 21 22 7.968492 $406.7900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 10 10 2.416285 $123.3500 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.087671 $4.4800 $51.0700
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.180822 $9.2300 $51.0400
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 6.780039 $346.1200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 20 5.666287 $289.2700 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.733333 $11.0000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.127778 $6.5200 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 67 74 45.772964 $2336.7300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 7 7 1.932571 $98.6500 $51.0500
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Subtotal (Total Children Is Unduplicated) 692 822 810.262550 $40518.6700 $50.0100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 16 18 10.848859 $54245.0000 $5000.0600
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 17 17 22.312267 $1115.6200 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 624 714 441.308893 $22065.6600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 32 33 16.148387 $403.7200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1892 2322 2962.577833 $148128.8300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 116 131 131.711109 $3292.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 583 679 856.209493 $42810.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 49 71 59.311107 $1482.7700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 437 490 577.370141 $28868.4800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 36 32.661112 $816.5300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1324 1392 1627.087720 $81354.3700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 101 111 128.569052 $3214.2400 $25.0000
DSTT -DSTT DIRECT SERVICE COORDINATOR TRAVEL 1 3 3.666667 $0.0000 $0.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 8 8 42.738096 $1068.4500 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 5 31.100000 $1555.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 214 250 1510.954755 $75547.7400 $50.0000
INTR -T1013 INTERPRETER 133 173 551.427227 $27571.3700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3135 4700 22104.043294 $221040.2900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 91 99 607.595235 $43406.5900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 9 52.142857 $2982.5700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 83 87 484.426190 $34607.3500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 12 12 84.142858 $4809.6000 $57.1600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.733333 $83.6000 $113.9900
SENS -V5264 EARMOLD 3 3 2.322222 $41.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 154 167 1041.445237 $74400.8200 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 8 8 21.733332 $301.6600 $13.8800
TRAV -TRAVS Travel by mile 1167 2102 156296.495225 $69551.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 5210 13642 189702.082501 $944997.1900 $4.9800
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Total 14640 190865.510922 $985515.8700 $5.1600
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Number of Children (Unduplicated) With at Least One Authorization 5483