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 16055 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 162 166 558.615076 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 7.533334 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 166 170 566.148410 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 82 102 59.690421 $2894.9600 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 40 41 44.714286 $954.6500 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.500000 $6.3100 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.405556 $8.7400 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.500000 $4.1300 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.500000 $12.6600 $25.3100
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 2.416667 $186.4000 $77.1300
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.722222 $14.9400 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.416667 $63.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.627778 $187.2000 $115.0000
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 18 23 9.691169 $484.5800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 429 447 678.965373 $33948.2700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 0.200000 $15.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.055556 $4.1700 $75.0600
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 2.155479 $161.6600 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 0.022222 $1.6700 $74.9300
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 8 3.850000 $288.7500 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 4.327701 $240.1900 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 15 15 24.110958 $1808.3300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 11 11 18.008220 $1350.6200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 2 2 3.500000 $262.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 14 14 27.500000 $1526.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 14 17.012329 $1275.9200 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 15 15 4.644443 $237.0900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 1.329604 $67.8800 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 44 45 22.510805 $1149.1700 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 14 14 4.016665 $205.0400 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.305556 $15.6000 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.505556 $127.9100 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 30 31 10.831885 $552.9600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.261111 $13.3300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 79 83 43.268592 $2208.8700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 8 8 3.283332 $167.6100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.104110 $5.2100 $50.0000
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Subtotal (Total Children Is Unduplicated) 769 920 1001.954263 $50877.0700 $50.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 18 24.582800 $122913.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 3.577778 $178.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 25 25 18.324105 $916.2100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.361644 $83.1700 $229.9700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 657 772 503.179315 $25159.1400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 30 30 15.035962 $375.9000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2102 2592 3097.068078 $154853.3800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 114 123 113.527781 $2838.2000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 621 792 918.134012 $45906.6900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 52 98 75.138885 $1878.4600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 542 632 742.513165 $37125.6400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 31 54 62.011111 $1550.2800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1505 1662 1685.198406 $84259.9100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 98 103 100.038895 $2500.9900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 3 4 5.333334 $391.0400 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 10 69.257144 $1731.4300 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 7 30.333334 $1516.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 283 318 1863.077780 $93153.8800 $50.0000
INTR -T1013 INTERPRETER 186 212 698.294683 $34914.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3206 4870 21937.673012 $219376.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 111 122 681.321426 $48673.6100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 18 21 128.428571 $7346.1100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 101 105 601.934522 $43002.2200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 10 11 101.683333 $5812.2200 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.377778 $24.5600 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.175342 $495.9700 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 0.916667 $418.0200 $456.0200
SENS -V5264 EARMOLD 3 3 1.627778 $29.3000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 189 206 1195.220633 $85386.6000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 32.142858 $446.1400 $13.8800
TRAV -TRAVS Travel by mile 1325 2165 142725.044457 $63512.6500 $0.4500
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Subtotal (Total Children Is Unduplicated) 5699 14965 177433.534589 $1086772.2500 $6.1200
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Total 16055 179001.637262 $1137649.3200 $6.3600
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Number of Children (Unduplicated) With at Least One Authorization 5976