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: 07-01-19 and 09-30-19 Date of Report: 11-04-19 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 15532 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 283 289 505.988088 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 10.228571 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 14 14 309.692065 $11458.6100 $37.0000
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Subtotal (Total Children Is Unduplicated) 299 306 825.908724 $11458.6100 $13.8700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 79 94 65.098016 $3157.2400 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 86 86 86.000000 $2020.1400 $23.4900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.088889 $2.1100 $23.7000
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 1.166667 $98.9800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 0.705556 $36.0400 $51.0700
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.044444 $0.9900 $22.3800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.022222 $1.0000 $44.9600
EVAL -96111 DEVELOPMENTAL EVALUATION 37 44 36.972600 $1848.6400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 492 509 839.218212 $41960.9300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.001370 $0.1100 $76.6400
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.001370 $0.1100 $76.6400
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 5 1.930431 $107.1400 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 1.500000 $83.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 13 13 24.004110 $1800.3100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 12 18.016437 $1351.2400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 4 4 2.010959 $150.8200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 30 44.591781 $2474.8400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 13 14 23.071233 $1730.3400 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 4.433333 $221.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.300000 $15.3200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 16 7.207686 $367.9500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.333334 $17.0200 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 6 1.750000 $89.3400 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 3.782344 $193.0900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 2.477778 $121.2600 $48.9400
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Subtotal (Total Children Is Unduplicated) 784 879 1177.728772 $58536.3900 $49.7000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 18 25.022223 $125111.5000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 5 2.676104 $133.8100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 10 16.927354 $846.3700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 3.655555 $840.7700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 714 838 699.229722 $34961.6400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 52 53 36.024659 $900.6200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1477 1671 2377.331305 $118866.5400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 173 187 241.938097 $6048.4600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 755 900 1139.217861 $56960.9000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 68 103 102.566665 $2564.1600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 546 621 751.686285 $37584.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 48 47.944447 $1198.6200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1340 1427 1591.064460 $79553.2000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 165 177 220.027776 $5500.6900 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 4 4 29.733333 $2180.0500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 15 214.986507 $5374.6600 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 263 292 1784.103958 $89205.2400 $50.0000
INTR -T1013 INTERPRETER 167 198 609.524951 $30476.2600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3553 5018 24729.641940 $247296.4500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 43 186.211110 $13302.8900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 16 17 111.101588 $6355.0100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 75 84 302.182545 $21587.9200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 19.000000 $1086.0400 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.377778 $24.5600 $65.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.022222 $466.1200 $455.9900
SENS -V5264 EARMOLD 4 4 2.877778 $51.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 97 101 509.328573 $36386.4300 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 5 5 14.785715 $205.2200 $13.8800
TRAV -TRAVS Travel by mile 1423 2497 159352.993799 $70912.0800 $0.4500
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Subtotal (Total Children Is Unduplicated) 5647 14347 195123.184310 $995982.3200 $5.1000
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Total 15532 197126.821806 $1065977.3200 $5.4100
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Number of Children (Unduplicated) With at Least One Authorization 6095