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: 01-01-18 and 03-31-18 Date of Report: 05-05-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 26837 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 161 174 250.835712 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.000000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 4.866667 $180.0700 $37.0000
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Subtotal (Total Children Is Unduplicated) 168 181 256.702379 $180.0700 $0.7000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 115 129 81.013568 $3929.1500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 2.988890 $153.4900 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 2.400000 $43.0100 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 312 314 321.288889 $6859.5200 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 3.532344 $44.5400 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 29 29 28.837301 $621.4400 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 19 19 16.111525 $133.0800 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 21 21 18.111525 $458.4100 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $69.9400 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 1.377778 $106.2700 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 8.285714 $384.6200 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 12.976365 $240.7100 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 3.450001 $71.3500 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 8 2.874505 $129.3500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 16 18 7.115601 $818.2800 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 24 30 28.372144 $1418.6200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 338 347 498.134008 $24906.7200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 45 51 64.634168 $4847.5700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 24 29 24.255095 $1819.1300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 13.016590 $976.2500 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 33 40 49.784172 $3733.8200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 41 47 41.690790 $2313.8300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 496 497 797.428241 $59807.2100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 248 248 432.543646 $32440.8200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 100 100 150.124762 $11259.3700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 559 560 857.500353 $47591.3000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 257 268 399.358222 $29951.8600 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 7 16.742858 $837.1400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 50 54 13.795585 $704.2600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 8 9 5.635160 $287.6800 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 69 72 51.225952 $2615.0800 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 261 281 110.616782 $5646.9800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 58 60 38.979221 $1989.8800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 9 9 5.143303 $262.5700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 26 27 17.376638 $887.0800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 205 218 75.450815 $3851.7600 $51.0500
SCREEN-T1023 SCREENING 24 26 23.496805 $1174.8500 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.0000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.000000 $459.4500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 3.435084 $175.3600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 417 437 235.179257 $12005.9200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 50 52 19.364687 $988.5600 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2668 4077 4501.648344 $267456.2100 $59.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 108 118 82.563341 $412816.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 1.511111 $75.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 32 33 29.058614 $1452.9500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 7 7 13.134920 $940.5800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 17 17 10.108295 $2324.8900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 683 789 501.769339 $25088.7600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 63 63 44.589430 $1114.7400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1906 2392 3295.462291 $164773.2400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 106 117 107.527779 $2688.2000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 606 726 846.642417 $42332.0900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 50 77 62.750002 $1568.7600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 506 562 678.739341 $33937.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 39 27.383330 $684.5800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1360 1461 1594.092046 $79704.5900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 94 102 103.010318 $2575.2600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 5 11.600000 $850.5100 $73.3200
DSTT -DSTT DIRECT SERVICE COORDINATOR TRAVEL 1 4 2.361111 $0.0000 $0.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 184 203 1915.657145 $47891.4300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 11.142857 $557.1500 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 8.077777 $403.8900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5049 5637 33936.375545 $1696819.2800 $50.0000
INTR -T1013 INTERPRETER 184 221 601.359719 $30067.9700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3044 4602 20683.405887 $206834.1000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 783 867 4166.380644 $297646.2100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 117 124 661.517860 $37838.7900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 800 883 4199.631946 $300021.8000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 48 51 286.192862 $16358.7600 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 0.386301 $25.1100 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 9 10 2.783562 $634.6600 $228.0000
SENS -V5060 BEHIND EAR HEARING AID
3 3 2.090411 $476.6100 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
5 5 1.852740 $844.8300 $455.9900
SENS -V5264 EARMOLD 31 33 14.381964 $258.8800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1254 1369 7294.963849 $521152.2600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 24 25 170.533334 $2367.0000 $13.8800
TRAV -TRAVS Travel by mile 1284 2021 139413.762826 $62039.1300 $0.4500
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Subtotal (Total Children Is Unduplicated) 7192 22579 220784.800914 $3995279.5400 $18.1000
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Total 26837 225543.151637 $4262915.8100 $18.9000
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Number of Children (Unduplicated) With at Least One Authorization 7991