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: 04-01-18 and 06-30-18 Date of Report: 08-10-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 29421 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 165 169 560.169044 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 7.533334 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 5.188888 $191.9900 $37.0000
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Subtotal (Total Children Is Unduplicated) 172 176 572.891266 $191.9900 $0.3400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 85 106 61.077560 $2962.2400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 14 8.738889 $448.7400 $51.3500
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 355 356 358.019157 $7643.7100 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 2.527093 $31.8700 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 23 25 10.908479 $235.0800 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 17 17 7.529833 $62.2000 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 16 16 6.896500 $174.5600 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $34.9700 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 17 17 9.692008 $747.5400 $77.1300
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.633333 $29.4000 $46.4200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 12 12 4.191629 $77.7600 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 7 4.644444 $96.0500 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 8.358502 $376.1300 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 12 8.902186 $1023.7500 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 20 25 10.178079 $508.9200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 432 450 684.965373 $34248.2700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 1.700000 $127.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 36 45.265904 $3394.9500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 19 23 27.037366 $2027.8000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 6.027701 $452.0800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 39 55 54.640640 $4098.0500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 33 41 33.716971 $1871.2900 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 441 442 705.943686 $52945.8200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 237 237 395.984330 $29698.8800 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 79 79 132.536988 $9940.2500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 582 583 871.414421 $48363.5400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 348 379 539.516635 $40463.7500 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 29.961905 $1498.1000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 59 61 23.984079 $1224.3600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 9 9 6.501826 $331.9200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 78 82 61.645434 $3146.9900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 293 311 121.383022 $6196.6200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 58 59 37.324939 $1905.4300 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 10 10 4.261112 $217.5300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 47 51 39.782801 $2030.9200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 270 288 116.351760 $5939.7600 $51.0500
SCREEN-T1023 SCREENING 22 23 21.321004 $1066.0500 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.175342 $2.6300 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 4.075267 $208.0400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 21 21 14.639801 $747.3500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 442 479 278.674601 $14226.3600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 63 63 26.694109 $1362.7200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 9 9 4.880897 $217.4400 $44.5500
VISD -99202 VISION EVAL DIAG (SIMPLE) 1 1 0.068493 $2.4600 $35.9800
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.104110 $5.2100 $50.0000
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Subtotal (Total Children Is Unduplicated) 2886 4436 4794.878209 $282539.9700 $58.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 97 116 119.459796 $597297.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 3.788889 $189.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 40 41 31.735217 $1586.7700 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.002740 $0.1900 $70.5500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 1.238585 $88.7000 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 18 19 7.368950 $1694.8500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 752 880 613.544702 $30677.4100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 71 74 47.623941 $1190.6000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2127 2617 3115.164827 $155758.2200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 115 124 113.884924 $2847.1300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 638 811 924.857026 $46242.8400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 52 98 75.138885 $1878.4600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 567 658 759.878245 $37993.9000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 31 54 62.011111 $1550.2800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1531 1689 1703.790390 $85189.5000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 98 103 100.038895 $2500.9900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 9 10 20.484127 $1501.9000 $73.3200
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 20.571429 $514.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 249 343 2490.592851 $62264.8400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 8 32.654763 $1632.7400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5504 6218 36617.547570 $1830877.9000 $50.0000
INTR -T1013 INTERPRETER 194 221 719.294683 $35964.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3206 4870 21937.673012 $219376.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 834 950 4601.121823 $328704.2400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 151 174 990.650000 $56665.1600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 837 939 4681.019481 $334412.1800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 58 67 384.536906 $21980.0900 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.679148 $44.1500 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 3.484932 $794.5600 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 4 4 2.317808 $528.4600 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 8 9 8.686661 $3961.1800 $456.0100
SENS -V5264 EARMOLD 31 33 27.559852 $496.0800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1287 1461 7618.130159 $544239.3000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 9 44.142856 $2524.9700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 29 29 172.495240 $2394.2300 $13.8800
TRAV -TRAVS Travel by mile 1325 2165 142725.044457 $63512.6500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7689 24809 230778.214881 $4479077.1800 $19.4100
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Total 29421 236145.984356 $4761809.1400 $20.1600
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Number of Children (Unduplicated) With at Least One Authorization 8516