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 15667 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 183 190 584.249509 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 10.369842 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 187 194 594.619351 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 81 102 51.551144 $2500.2400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $51.3500 $51.3500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 50 52 50.411112 $1076.2800 $21.3500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.744444 $6.1500 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.744444 $18.8400 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 0.055556 $4.2900 $77.1900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.744444 $13.8100 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.133333 $44.1200 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 0.694445 $31.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.055556 $6.3900 $115.0900
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 5.428571 $678.5800 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 15 19 7.376252 $368.8200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 395 411 630.726256 $31536.3000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.383333 $28.7500 $74.9900
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 15 15 10.811035 $810.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 14 14 2.122223 $159.1700 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 0.311035 $23.3300 $75.0200
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 13 13 9.983333 $748.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 23 24 8.605480 $477.6100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 11 11 17.010958 $1275.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 10.005479 $750.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 11 11 15.515068 $1163.6300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 13 13 21.008219 $1165.9600 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 11.504110 $862.8100 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 15 15 7.145237 $364.7600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.054795 $2.8000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 4.416667 $225.4700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 28 29 11.137779 $568.5800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 12 12 2.900000 $148.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.844445 $43.1100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.233333 $62.9600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 26 26 11.656350 $595.0600 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 1.533333 $23.0000 $15.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 61 62 31.383669 $1602.1300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 7 7 1.727779 $88.2100 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.038356 $1.9200 $50.0600
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Subtotal (Total Children Is Unduplicated) 720 880 934.997573 $47630.6000 $50.9400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 19 12.133182 $60666.5000 $5000.0500
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.488889 $74.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 13 14 5.777778 $288.8900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 2.300000 $529.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 623 744 452.163201 $22608.3700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 27 28 15.812463 $395.3100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2016 2532 3021.470483 $151073.5700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 135 156 227.005919 $5675.1600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 593 730 846.475398 $42323.7900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 81 64.311107 $1607.7700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 497 559 623.468529 $31173.4100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 46 52.622222 $1315.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1456 1580 1677.076148 $83853.8500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 100 115 136.947621 $3423.7000 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 3 2.923810 $214.3700 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 10 25.850792 $646.2700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 9 53.866667 $2693.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 234 267 1446.399999 $72320.0400 $50.0000
INTR -T1013 INTERPRETER 187 235 690.265600 $34513.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3181 4938 22086.861922 $220868.6700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 95 96 590.642855 $42195.5400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 19 21 150.750002 $8622.8900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 97 100 501.834124 $35851.0400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 18 19 143.357143 $8194.3000 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.561340 $36.4900 $65.0100
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.533333 $60.8000 $113.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.055556 $25.3500 $456.3600
SENS -V5264 EARMOLD 3 3 1.032725 $18.5900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 161 176 1041.961902 $74437.7500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 7 7 131.071430 $1819.2700 $13.8800
TRAV -TRAVS Travel by mile 1320 2097 144615.226470 $64353.7800 $0.4500
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Subtotal (Total Children Is Unduplicated) 5556 14593 178622.248610 $971881.0700 $5.4400
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Total 15667 180151.865534 $1019511.6600 $5.6600
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Number of Children (Unduplicated) With at Least One Authorization 5839