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: 10-01-19 and 12-31-19 Date of Report: 02-01-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 28422 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 1 1 0.811111 $30.0100 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 282 292 340.664836 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 1.466667 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 664 693 21068.269843 $779526.0800 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 904 988 21411.212457 $779556.0900 $36.4100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 93 109 69.637215 $3377.4100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 13 21.980082 $1241.6600 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.139726 $22.4600 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 273 274 291.850315 $6855.5600 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 12 12 9.191249 $127.4800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 23 23 18.480951 $437.9900 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 13 11.674886 $106.0100 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.450000 $4.4800 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 22 22 32.655534 $908.8000 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 3.000000 $115.4100 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 21 21 22.199999 $1883.4400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 9 9 6.000000 $306.4200 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 17 17 14.353425 $239.7000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 7.768189 $174.0100 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 6.939878 $312.3000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 3.947183 $453.9200 $115.0000
BEHV -H2014BA BEHAVIOR ANALYSIS-ASSOCIATE 1 1 3.285714 $160.2100 $48.7600
EVAL -96111 DEVELOPMENTAL EVALUATION 28 35 20.179220 $1008.9600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 420 435 676.898416 $33844.9100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 7 9.005479 $675.4100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 36 36 45.160428 $3387.0100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 15 15 20.130441 $1509.7800 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 7 7 6.015069 $451.1300 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 46 59 85.400687 $6405.0300 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 58 58 49.880749 $2768.3400 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 491 492 847.697264 $63577.2100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 232 233 428.573968 $32143.0600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 166 166 178.291790 $13371.8200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 661 670 1048.814869 $58209.1700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 379 422 678.818198 $50911.3300 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 1.500000 $75.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 3 3 4.500001 $225.0100 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 45 49 11.505554 $587.3500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 3.294444 $168.1800 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 41 42 24.345282 $1242.8300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 296 307 178.449827 $9109.8600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 38 38 5.665146 $289.2100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 7 7 3.355556 $171.3000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 17 17 12.516058 $638.9400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 232 247 121.125672 $6183.4800 $51.0500
SCREEN-T1023 SCREENING 45 45 41.144445 $2057.2300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 13.631745 $695.9000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 5.000000 $255.2500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 339 358 174.387627 $8902.4800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 4 4 2.338888 $119.4000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 28 28 58.098411 $2843.3400 $48.9400
VISD -99204 VISION EVAL DIAG (MOD COMPLEXITY) 1 1 1.000000 $75.7200 $75.7200
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.366667 $18.3400 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2836 4352 5281.646247 $318649.2100 $60.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 99 112 80.777005 $403884.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 1.038889 $51.9500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 18 18 19.830160 $991.5200 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.450000 $32.2200 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 4.305403 $308.3100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 37 37 34.726560 $7987.1200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 776 917 881.138055 $44057.0900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 97 99 78.528486 $1963.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1429 1576 2180.855828 $109042.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 171 186 223.976192 $5599.4100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 754 891 1004.432921 $50221.5700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 67 109 133.933334 $3348.3400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 511 576 637.052830 $31852.6500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 45 54.823811 $1370.6000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1347 1421 1501.419056 $75070.9700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 163 174 198.694448 $4967.3700 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 7 7 12.476190 $914.7500 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 274 326 3906.776168 $97669.4200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5491 5859 35409.202198 $1770460.5000 $50.0000
INTR -T1013 INTERPRETER 211 239 753.513565 $37675.6900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3488 4791 22891.268690 $228912.7500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 684 724 3703.486495 $264577.1100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 274 304 1543.497618 $88288.0900 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 757 798 3819.375684 $272856.3200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 125 135 739.740470 $42283.6400 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 9 9 2.632876 $600.3000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 3.000000 $1368.0000 $456.0000
SENS -V5264 EARMOLD 25 25 17.058144 $307.0500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1035 1112 5983.904793 $427490.3000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.428571 $81.7200 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 102 114 577.949205 $8021.9300 $13.8800
TRAV -TRAVS Travel by mile 1428 2465 150755.710083 $67086.2900 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7830 23082 237158.003728 $4049343.4800 $17.0700
-------------------------------------------------------------------------------------------------------------------------------------
Total 28422 263850.862432 $5147548.7800 $19.5100
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 8924