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: 10-01-17 and 12-31-17 Date of Report: 02-03-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 28180 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 188 195 587.682843 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 10.369842 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 8 8 5.666668 $209.6700 $37.0000
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Subtotal (Total Children Is Unduplicated) 200 207 603.719353 $209.6700 $0.3500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 89 110 54.571084 $2646.7100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 8.510318 $437.0000 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $17.9200 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 318 325 320.101587 $6834.1700 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.230137 $15.5100 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 37 37 30.200514 $650.8200 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 18 18 9.086073 $75.0500 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 18 18 8.125494 $205.6600 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 4 4.000000 $139.8800 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 0.916667 $70.7100 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 1.443836 $67.0200 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 4.461415 $82.7600 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 14 14 9.741096 $201.4500 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 11 11 6.196012 $278.8200 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 6.199284 $712.9200 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 5.428571 $678.5800 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 16 20 7.461184 $373.0700 $50.0000
EXIT -EXIT EXIT ASSESSMENT 395 411 630.726256 $31536.3000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 1.150000 $86.2500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 42 55 53.288203 $3996.6200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 28 43 22.810958 $1710.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 12 13 8.028844 $602.1700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 33 46 49.228875 $3692.1700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 55 77 59.102590 $3280.2100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 464 465 676.493125 $50737.0600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 209 209 335.454194 $25159.1100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 131 131 170.880035 $12816.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 486 487 726.451645 $40318.1000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 204 206 259.209195 $19440.6800 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 11 15 27.768252 $1388.4200 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 58 58 22.162361 $1131.3900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 15 15 11.427094 $583.3500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 60 61 40.939348 $2089.9600 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 258 273 110.833620 $5658.0900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 48 54 44.862234 $2290.2300 $51.0500
PSTH -97001 EVAL BY LICENSED PT, INITIAL 1 1 0.266667 $13.6200 $51.0600
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 4.622223 $235.9700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 23 24 14.540105 $742.2700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 214 224 109.048755 $5566.9900 $51.0500
SCREEN-T1023 SCREENING 33 34 28.793759 $1439.6900 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 1.955555 $29.3300 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 42.750001 $2182.3900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 10 11 13.405893 $684.3700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 397 412 252.395454 $12884.8100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 43 44 22.909817 $1169.5400 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.038356 $1.9200 $50.0600
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Subtotal (Total Children Is Unduplicated) 2616 3990 4220.216686 $244955.8400 $58.0400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 101 114 76.772268 $383861.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 4 2.700000 $135.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 25 26 21.185715 $1059.2900 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 0.416667 $29.8400 $71.6200
AUDE -V5160 DISPENSING FEE BINAURAL 23 23 13.079604 $3008.3100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 736 881 590.187411 $29509.5800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 78 79 43.492899 $1087.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2037 2559 3045.833181 $152291.7100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 135 156 227.005919 $5675.1600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 598 735 848.530953 $42426.5700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 81 64.311107 $1607.7700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 516 580 638.801840 $31940.0700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 46 52.622222 $1315.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1473 1598 1696.115038 $84805.8000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 100 115 136.947621 $3423.7000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 9 10.085715 $739.4900 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 5.142857 $128.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 223 257 2146.014284 $53650.3700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 12.857143 $642.8600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 10 12 58.446282 $2922.3200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5392 6060 36023.639459 $1801182.2400 $50.0000
INTR -T1013 INTERPRETER 195 244 726.859250 $36342.9600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3181 4939 22088.061922 $220880.6700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 796 863 4444.048461 $317482.8200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 115 124 799.190478 $45713.6700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 786 848 3983.821837 $284604.1700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 75 79 495.400399 $28317.0800 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.761340 $49.4900 $65.0100
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.533333 $60.8000 $113.9900
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 1.597261 $364.1600 $227.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
5 5 3.884671 $1771.4200 $456.0000
SENS -V5264 EARMOLD 23 24 15.674019 $282.1300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1248 1384 7568.212308 $540673.0200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 11.000000 $629.2000 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 26 26 275.152381 $3819.1200 $13.8800
TRAV -TRAVS Travel by mile 1320 2098 144616.426470 $64354.3200 $0.4500
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Subtotal (Total Children Is Unduplicated) 7488 23983 230744.812315 $4146788.0000 $17.9700
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Total 28180 235568.748354 $4391953.5100 $18.6400
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Number of Children (Unduplicated) With at Least One Authorization 8257