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: 10-01-18 and 12-31-18 Date of Report: 02-06-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 28255 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 258 263 463.935105 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 4 20.476190 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 5.566667 $205.9700 $37.0000
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Subtotal (Total Children Is Unduplicated) 266 272 489.977962 $205.9700 $0.4200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 109 125 73.215880 $3550.9700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 11.757828 $664.2000 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 2.066667 $40.7300 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 321 325 334.322223 $7853.2300 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 5.255556 $72.9000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 34 34 14.197500 $336.4900 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 19 19 37.919516 $344.3100 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 25 25 42.232302 $1175.3300 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.066667 $79.5100 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 7 7 3.872222 $328.5200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.422222 $21.5600 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 14 14 16.500816 $275.5700 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 5.990869 $134.2000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 10.323810 $464.5700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 13.924114 $1601.2600 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 25 34 35.849846 $1792.4900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 373 383 625.021702 $31251.0900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 46 56.377778 $4228.3400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 27 38 32.961035 $2472.0800 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 9 6.047185 $453.5400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 33 46 55.902208 $4192.6700 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 34 45 46.273592 $2568.1900 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 349 351 628.657724 $47149.3400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 219 221 404.145396 $30310.9200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 45 45 83.515068 $6263.6300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 534 534 779.956934 $43287.6400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 436 490 714.272011 $53570.4200 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.566667 $28.3400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 67 67 18.844446 $962.0200 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 3.418949 $174.5300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 73 75 56.074278 $2862.5900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 281 292 164.720966 $8409.0300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 47 47 17.174607 $876.7800 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 5 6 14.321330 $731.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 29 29 19.884400 $1015.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 259 273 103.007407 $5258.5200 $51.0500
SCREEN-T1023 SCREENING 38 38 31.866667 $1593.3400 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 10 4.316668 $220.3700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 11 11 6.422223 $327.8600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 407 422 220.640301 $11263.6800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 23 23 14.515981 $741.0400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 15 15 6.732953 $329.5100 $48.9400
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Subtotal (Total Children Is Unduplicated) 2710 4155 4725.556514 $279277.5100 $59.1000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 126 135 118.932462 $594663.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 2.433334 $121.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 28 28 34.714145 $1735.7100 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 0.287672 $20.6000 $71.5900
AUD -92633 AUD REHAB POSTLING HEARING LOSS 7 7 5.862797 $419.8400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 26 26 17.787366 $4091.0600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 690 838 571.744509 $28587.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 74 76 56.421595 $1410.5500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1907 2224 2795.823673 $139791.1000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 151 171 153.135712 $3828.3900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 639 787 941.283748 $47064.1400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 68 119 90.494440 $2262.3500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 550 603 666.205222 $33310.2900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 43 47.788888 $1194.7200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1455 1555 1622.853908 $81142.6400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 126 137 125.371424 $3134.2700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 12 13 25.515873 $1870.8200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 242 271 2594.904746 $64872.6400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 5 5 15.383333 $769.1700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5749 6375 37916.527353 $1895826.5900 $50.0000
INTR -T1013 INTERPRETER 198 216 765.661815 $38283.1200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3415 4797 23163.400995 $231634.0000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 769 819 4236.558731 $302659.7800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 160 178 918.366670 $52530.6000 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 825 858 4309.217447 $307850.5200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 68 69 389.071430 $22239.3200 $57.1600
RSPT -RSPT RESPITE 1 1 3.571429 $0.0000 $0.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.675495 $43.9100 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 3.460274 $788.9300 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.866667 $425.6100 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 6.623810 $3020.4500 $456.0000
SENS -V5264 EARMOLD 27 27 21.863992 $393.5500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1111 1188 6106.422525 $436242.9000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 34.142858 $1952.9700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 41 44 162.180953 $2251.0700 $13.8800
TRAV -TRAVS Travel by mile 1387 2195 148067.297686 $65889.9500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7864 23828 235993.854977 $4372323.6200 $18.5300
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Total 28255 241209.389453 $4651807.0900 $19.2900
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Number of Children (Unduplicated) With at Least One Authorization 8698