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 14608 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 143 146 329.986022 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 26.361905 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 146 149 356.347927 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 92 106 69.739248 $3382.3600 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 43 43 43.000000 $918.0500 $21.3500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $8.2600 $8.2600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 2.455556 $189.4000 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $18.5500 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 2.333333 $48.2500 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.455556 $20.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.455556 $52.3900 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 13 17 7.437972 $371.9100 $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 7 7 7.866591 $590.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 2.638888 $197.9100 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 8 9.133333 $685.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 11 5.916589 $328.3700 $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 8 8 11.531888 $864.8900 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 15 16 5.211111 $266.0300 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 7 6.172222 $315.0900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 33 34 14.079298 $718.7400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 13 13 3.311110 $169.0300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.333333 $17.0200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.221918 $62.3800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 19 7.605557 $388.2700 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.177778 $60.1300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 50 55 25.594444 $1306.5900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 17 17 8.029299 $409.8900 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.147945 $7.4000 $49.9800
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Subtotal (Total Children Is Unduplicated) 662 792 916.053252 $46504.6300 $50.7700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 11 6.885236 $34426.0000 $4999.9700
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 24 24 11.111372 $555.5700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.060274 $13.8700 $230.1000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 637 737 502.750256 $25137.7400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 25 25 11.245796 $281.1500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2020 2405 3623.466756 $181173.2800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 121 133 155.772222 $3894.3100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 567 663 912.677608 $45633.9000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 48 79 80.261114 $2006.5400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 500 553 760.170165 $38008.4900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 51 54.533337 $1363.3400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1429 1507 1703.445288 $85172.2300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 100 103 123.705553 $3092.6300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 26.714286 $667.8600 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 7 44.866666 $2243.3300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 214 231 1466.609530 $73330.4700 $50.0000
INTR -T1013 INTERPRETER 178 232 760.630395 $38031.5300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3111 4531 22470.477347 $224704.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 96 101 578.923808 $41358.3200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 17 19 122.321429 $6996.7900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 87 90 514.754761 $36774.0800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 10 60.142856 $3437.7700 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.133333 $8.6600 $64.9800
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.455556 $207.7500 $456.0400
SENS -V5264 EARMOLD 1 1 0.455556 $8.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 143 153 962.511911 $68761.8100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 3 3 18.571428 $257.7700 $13.8800
TRAV -TRAVS Travel by mile 1109 1992 124742.766712 $55510.5400 $0.4500
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Subtotal (Total Children Is Unduplicated) 5258 13667 159716.420551 $973058.5200 $6.0900
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Total 14608 160988.821730 $1019563.1500 $6.3300
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Number of Children (Unduplicated) With at Least One Authorization 5525