Summary Report for FSPSAs Initiated During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start 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 starting 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 29127 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
CASE -CASE NON-TCM CASE MANAGEMENT 2 2 1.377778 $50.9800 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 263 268 428.852386 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 4 4 8.988888 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 658 674 23773.568245 $879621.7800 $37.0000
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Subtotal (Total Children Is Unduplicated) 872 948 24212.787297 $879672.7600 $36.3300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 104 116 77.862860 $3776.3500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 8 8 6.488660 $366.5400 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 228 228 242.734127 $5701.8300 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 10 7.011110 $97.2400 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 21 21 12.944446 $306.7900 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 9 8.055555 $73.1400 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 19 20 19.918959 $554.3500 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 14 15 16.583334 $1406.9400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 18 19 19.000000 $317.3000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 5 5 4.688888 $105.0300 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 13 13 9.400153 $423.0100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 4.246499 $488.3400 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 36 43 38.125569 $1906.2900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 481 498 830.724158 $41536.2200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 7 8.208219 $615.6200 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 38 38 62.015069 $4651.1300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 14 14 20.017807 $1501.3400 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 11.012330 $825.9200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 40 58 73.763928 $5532.2900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 47 51 53.777692 $2984.6500 $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 449 450 762.658906 $57199.3600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 231 231 416.602734 $31245.2200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 109 109 100.705494 $7552.8300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 620 632 978.968484 $54332.7300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 431 497 779.293144 $58447.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 4.299999 $215.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 3 3 4.400000 $220.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 60 63 18.130164 $925.5700 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.416667 $72.3200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 39 40 32.113785 $1639.4100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 311 326 192.900927 $9847.6000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 28 30 7.266671 $370.9900 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 5 5 4.466667 $228.0300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 19 20 17.227397 $879.4600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 247 271 127.321981 $6499.8000 $51.0500
SCREEN-T1023 SCREENING 31 31 29.334920 $1466.7400 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 6.739498 $344.0600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 13 13 10.333942 $527.5500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 319 341 170.274219 $8692.5400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 6 6 6.000000 $306.3000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 25 26 26.619571 $1302.7600 $48.9400
VISD -99202 VISION EVAL DIAG (SIMPLE) 1 1 0.355556 $12.7900 $35.9800
VISD -99204 VISION EVAL DIAG (MOD COMPLEXITY) 1 1 0.866667 $65.6300 $75.7200
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.505556 $25.2800 $50.0000
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Subtotal (Total Children Is Unduplicated) 2713 4305 5228.882312 $315762.0100 $60.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 112 128 105.827929 $529139.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 7 7 4.537748 $226.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 12 13 10.704566 $535.2300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 6 6 4.944445 $354.0800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 20 20 23.538889 $5413.9500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 839 968 949.969606 $47498.6200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 119 124 91.023772 $2275.6100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1406 1577 2183.881489 $109194.0100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 208 219 231.557935 $5788.9400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 798 942 1059.129274 $52956.3600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 82 128 157.151586 $3928.7900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 475 530 637.849994 $31892.4800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 32 84.768252 $2119.2000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1310 1371 1387.260272 $69362.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 208 215 200.683332 $5017.0800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 360 451 3877.260334 $96931.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5627 6043 37703.130212 $1885156.1400 $50.0000
INTR -T1013 INTERPRETER 187 231 757.477338 $37873.8800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3647 5035 24442.577465 $244425.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 708 752 3632.439336 $259501.2800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 261 300 1583.964311 $90602.7100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 732 779 3966.681012 $283379.4200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 122 152 781.403186 $44665.0100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.685236 $156.2300 $227.9900
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 2.205556 $1005.7500 $456.0100
SENS -V5264 EARMOLD 16 17 8.851749 $159.3300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1046 1132 6490.991245 $463716.1000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 11.486509 $657.0300 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 116 152 723.234933 $10038.4900 $13.8800
TRAV -TRAVS Travel by mile 1312 2538 149192.940053 $66390.8700 $0.4500
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Subtotal (Total Children Is Unduplicated) 7820 23874 240311.157564 $4350884.1700 $18.1100
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Total 29127 269752.827173 $5546318.9500 $20.5600
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Number of Children (Unduplicated) With at Least One Authorization 8451