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 14766 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 158 169 244.569045 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 1.000000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 159 170 245.569045 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 108 121 78.093325 $3787.5200 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 44 44 43.155556 $921.3700 $21.3500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.155556 $9.5500 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.155556 $3.9400 $25.3200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 0.594445 $45.8500 $77.1400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.155556 $21.4400 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.177778 $3.6800 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.438889 $19.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.438889 $50.4700 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 23 29 28.366588 $1418.3400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 338 347 498.134008 $24906.7200 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 3.884627 $291.3400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 1.222221 $91.6600 $74.9900
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 5.061111 $379.5800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 9 9 5.376331 $298.3800 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 23.510958 $1763.3300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 2.005479 $150.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 14 14 23.010958 $1277.1100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 13.500000 $1012.5000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 10 11 4.822222 $246.1700 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 3 4 2.174049 $110.9900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 12 12 9.205099 $469.9200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 38 40 15.960687 $814.7900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 10 11 3.927777 $200.5100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 0.101370 $5.1800 $51.0700
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.117809 $6.0100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 18 18 7.399999 $377.7600 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.073973 $54.8300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 78 81 50.871890 $2597.0300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF
VOICE AND 7 7 2.483866 $126.8000 $51.0500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 1.000000 $50.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 685 810 837.576572 $42115.0200 $50.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 15 7.626940 $38134.0000 $4999.9100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 16 16 15.658611 $782.9400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.294444 $21.0800 $71.6000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 608 696 405.517522 $20276.1400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 33 33 18.795287 $469.8800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1884 2369 3270.491656 $163524.7000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 106 117 107.527779 $2688.2000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 598 718 843.781306 $42189.0400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 50 77 62.750002 $1568.7600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 498 554 672.544897 $33627.2900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 39 27.383330 $684.5800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1336 1437 1578.186492 $78909.3100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 93 101 102.010318 $2550.2600 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 3.133333 $229.7300 $73.3200
DSTT -DSTT DIRECT SERVICE COORDINATOR TRAVEL 1 4 2.361111 $0.0000 $0.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 6.000000 $150.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 3 3 3.844444 $192.2200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 253 280 1540.855947 $77042.8100 $50.0000
INTR -T1013 INTERPRETER 183 219 591.931147 $29596.5500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3044 4602 20683.405887 $206834.1000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 117 122 595.990477 $42577.5500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 19 19 134.840475 $7712.8700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 93 99 491.161906 $35088.6000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 11 11 58.857144 $3364.2700 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID
1 1 0.438889 $200.1400 $456.0100
SENS -V5264 EARMOLD 3 3 1.305556 $23.5000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 207 218 1199.766667 $85711.3100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 6 6 37.857143 $525.4600 $13.8800
TRAV -TRAVS Travel by mile 1284 2021 139413.762826 $62039.1300 $0.4500
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Subtotal (Total Children Is Unduplicated) 5341 13786 171880.081536 $936944.4000 $5.4500
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Total 14766 172963.227153 $979059.4100 $5.6600
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Number of Children (Unduplicated) With at Least One Authorization 5600