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
Eligibility Filter: Program Patients
With the filters selected there were 22117 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 183 186 422.749515 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 26.361905 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 1.333334 $49.3400 $37.0000
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Subtotal (Total Children Is Unduplicated) 188 191 450.444754 $49.3400 $0.1100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 113 131 84.761623 $4110.9500 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 1.244749 $22.3100 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 83 83 82.866667 $1769.2000 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 2.244749 $28.3100 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 6 6 3.031278 $65.3200 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 5.146119 $42.5100 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 4.146119 $104.9400 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.866667 $65.2800 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 3.705556 $285.8100 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.147945 $6.8700 $46.4100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 5 5 2.294064 $42.5500 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 7 4.466667 $92.3700 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 0.625419 $28.1500 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.455556 $52.3900 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 17 21 7.706238 $385.3300 $50.0000
EXIT -EXIT EXIT ASSESSMENT 489 505 810.180863 $40509.0600 $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 11 11 10.876180 $815.7200 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 3.400000 $255.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 2.116514 $158.7500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 13 13 9.308144 $698.1200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 17 18 15.917959 $883.4400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 76 76 60.200001 $4514.9900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 25 32.542463 $2440.7000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 47 47 42.223290 $3166.7300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 110 110 94.080820 $5221.4800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 57 57 63.830515 $4787.3000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 27 28 8.977778 $458.3200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.265449 $13.5500 $51.0600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 27 28 26.571918 $1356.5000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 86 89 40.332799 $2058.9800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 32 32 11.934122 $609.2200 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.333333 $17.0200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 9 9 5.646195 $288.2300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 47 48 29.348086 $1498.2300 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 1.300000 $66.3700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 5.177778 $264.3300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 147 156 105.807274 $5401.4500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 32 32 15.582343 $795.4700 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.147945 $7.4000 $49.9800
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Subtotal (Total Children Is Unduplicated) 1249 1595 1602.522296 $83491.9400 $52.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 32 33 29.017427 $145087.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.866667 $43.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 29 29 27.166134 $1358.3000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 1.560274 $358.8700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 885 1023 760.403402 $38020.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 35 36 14.620568 $365.5200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2696 3243 4900.915953 $245045.7000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 149 164 191.969049 $4799.2300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 824 946 1322.272054 $66113.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 58 94 92.788892 $2319.7300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 656 720 1020.091591 $51004.5300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 40 61 67.700003 $1692.5100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2020 2127 2568.063020 $128403.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 132 135 180.183333 $4504.5800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.255556 $18.7400 $73.3300
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 39 44 277.750796 $6943.7700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 53.571429 $2678.5700 $50.0000
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 1348 1516 10448.219715 $522410.7300 $50.0000
INTR -T1013 INTERPRETER 205 266 920.152619 $46007.6400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4192 6185 30894.483618 $308944.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 225 239 1339.144055 $95668.4100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 24 26 159.035715 $9096.8400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 221 232 1283.028575 $91659.5000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 12 12 74.428571 $4254.3400 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.896043 $58.2400 $65.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
2 2 1.455556 $663.7500 $456.0100
SENS -V5264 EARMOLD 3 3 2.022223 $36.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 412 434 2719.816683 $194303.6500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 17.428571 $996.9200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 10 10 60.738096 $843.0500 $13.8800
TRAV -TRAVS Travel by mile 1502 2732 177401.490175 $78943.6700 $0.4500
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Subtotal (Total Children Is Unduplicated) 7666 20331 236877.403029 $2054888.7100 $8.6700
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Total 22117 238930.370079 $2138429.9900 $8.9500
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Number of Children (Unduplicated) With at Least One Authorization 8047