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: 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 26675 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 151 154 347.713008 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 26.361905 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 3.166666 $117.1600 $37.0000
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Subtotal (Total Children Is Unduplicated) 157 160 377.241579 $117.1600 $0.3100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 93 108 70.342749 $3411.6300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 6.961111 $357.4500 $51.3500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 327 329 327.466667 $6991.4100 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 0.107763 $1.3600 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 19 20 9.668567 $208.3500 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 18 18 11.637356 $96.1200 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 7.129593 $180.4500 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $34.9700 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 13 9.850000 $759.7300 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 2.466667 $114.5000 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 7.417264 $137.5900 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 10 10 9.029986 $186.7400 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 9 15.900348 $715.5100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 16.079496 $1849.1400 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 14 18 7.522904 $376.1600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 356 365 611.770635 $30588.5400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.711111 $53.3300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 31 35 41.185463 $3088.9100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 16 21 20.822067 $1561.6400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 7.020548 $526.5500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 28 34 32.922526 $2469.1900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 42 53 50.824809 $2820.7800 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 462 463 674.449289 $50583.7700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 207 207 331.454194 $24859.1100 $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 486 489 703.308787 $39033.6700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 206 209 261.292529 $19596.9300 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 7 8 20.076188 $1003.8200 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 59 62 21.059917 $1075.1200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 4.355556 $222.3500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 65 67 44.690941 $2281.4700 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 259 271 115.409876 $5891.7000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 54 57 16.067579 $820.2500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 5.405556 $275.9600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 30 30 19.449998 $992.9200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 235 248 139.126746 $7102.4400 $51.0500
SCREEN-T1023 SCREENING 27 28 24.812633 $1240.6300 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.076712 $1.1500 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 9.485693 $484.2500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 10 11 4.033562 $205.9100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 366 387 185.847852 $9487.5200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 86 86 36.484249 $1862.5400 $51.0500
VISD -99202 VISION EVAL DIAG (SIMPLE) 1 1 0.186301 $6.7000 $35.9800
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.147945 $7.4000 $49.9800
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Subtotal (Total Children Is Unduplicated) 2486 3878 4055.939768 $236381.6500 $58.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 93 108 89.655501 $448277.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.033334 $51.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 38 38 24.644708 $1232.2500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 12.624941 $904.0800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 17 17 7.103576 $1633.8300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 743 866 628.573088 $31428.9000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 73 73 37.248606 $931.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2043 2431 3651.268343 $182563.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 121 133 155.772222 $3894.3100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 574 670 917.027608 $45851.4000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 48 79 80.261114 $2006.5400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 517 570 769.856673 $38492.8100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 51 54.533337 $1363.3400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1455 1534 1727.765924 $86388.2700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 100 103 123.705553 $3092.6300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 19.247619 $1411.2300 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 47.428571 $1185.7200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 210 218 2022.349224 $50558.7100 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 8 45.759523 $2287.9800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5345 5805 38675.871780 $1933792.4000 $50.0000
INTR -T1013 INTERPRETER 186 241 787.081188 $39354.0700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3111 4531 22470.477347 $224704.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 776 826 4686.559942 $334807.6700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 110 117 698.396427 $39948.3000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 781 828 4689.025280 $334983.8900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 53 57 302.457142 $17288.4500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.336072 $21.8500 $65.0100
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 1.520548 $346.7000 $228.0100
SENS -V5060 BEHIND EAR HEARING AID
2 2 1.145205 $261.1100 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
7 7 14.218765 $6483.7700 $456.0000
SENS -V5264 EARMOLD 25 25 29.423900 $529.6400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1168 1254 7541.423846 $538759.0400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 5.785714 $330.9400 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 32 33 250.714286 $3479.9200 $13.8800
TRAV -TRAVS Travel by mile 1109 1992 124742.766712 $55510.5400 $0.4500
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Subtotal (Total Children Is Unduplicated) 7161 22637 215313.063619 $4434158.1100 $20.5900
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Total 26675 219746.244966 $4670656.9200 $21.2500
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Number of Children (Unduplicated) With at Least One Authorization 7592