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: 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 28116 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 0.800000 $29.6000 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 251 252 419.592889 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 2.285714 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 668 670 24717.972220 $914565.0100 $37.0000
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Subtotal (Total Children Is Unduplicated) 878 924 25140.650823 $914594.6100 $36.3800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 86 101 76.721538 $3721.0100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 15.388889 $869.3200 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 299 301 309.906350 $7279.7000 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 2.911111 $40.3800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 21 21 9.361113 $221.8600 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 6.551751 $59.4900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 5.633942 $156.7900 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 16 16 20.155556 $1710.0000 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 4 4 2.650381 $135.3600 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 14.650381 $244.6600 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.922222 $43.0600 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 5.805556 $261.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.251446 $143.9200 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 24 31 16.691169 $834.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 384 394 627.857992 $31392.8900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 45 45 64.060428 $4804.5100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 15 15 22.030441 $1652.2800 $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 47 60 88.513397 $6638.4800 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 61 61 59.500309 $3302.2300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 491 492 847.197264 $63539.7100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 231 232 426.573968 $31993.0600 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 165 165 176.291790 $13221.8200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 665 674 1059.973970 $58828.4900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 382 425 680.323678 $51024.2300 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 4 20.000000 $1000.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 6 22.366667 $1118.3400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 49 50 12.681274 $647.3500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 15.172222 $774.5400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 52 52 32.719710 $1670.3300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 334 343 199.601773 $10189.6700 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 33 35 10.109056 $516.0600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 3.455556 $176.4100 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 24 24 43.443736 $2217.8000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 222 235 128.344468 $6551.9800 $51.0500
SCREEN-T1023 SCREENING 50 51 48.744445 $2437.2300 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.855556 $12.8300 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 14 14 17.857936 $911.6500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 5.642389 $288.0400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 403 424 228.609972 $11670.5800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 6 6 4.288889 $218.9500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 40 40 31.495357 $1541.3800 $48.9400
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Subtotal (Total Children Is Unduplicated) 2775 4406 5377.334196 $324740.6700 $60.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 89 100 107.928025 $539640.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 5 5 2.805555 $140.2800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 18 18 18.400001 $920.0100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 6 6 8.788889 $629.3700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 13.338889 $3067.9500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 783 912 848.694648 $42434.9000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 89 92 90.759167 $2268.9800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1382 1510 2359.850736 $117992.4400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 208 216 240.911109 $6022.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 806 942 1184.411481 $59220.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 79 133 142.922235 $3573.0900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 504 552 746.578166 $37328.8700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 44 48.311115 $1207.7900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1406 1456 1621.497619 $81074.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 195 200 209.938892 $5248.4800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 212 237 2170.631752 $54265.7900 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5569 5884 39997.515109 $1999875.8200 $50.0000
INTR -T1013 INTERPRETER 196 233 673.365949 $33668.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3493 4655 24533.997159 $245339.9700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 679 710 4073.173014 $290987.3900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 332 350 2038.369847 $116594.7300 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 754 795 4479.242459 $319997.1000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 126 131 781.998340 $44699.0100 $57.1600
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.608219 $138.6700 $227.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.477778 $1129.8800 $456.0000
SENS -V5264 EARMOLD 20 20 19.641554 $353.5500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1036 1106 6539.663890 $467193.5200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 9 9 94.642857 $5413.5700 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 134 138 854.538096 $11860.9800 $13.8800
TRAV -TRAVS Travel by mile 1245 2315 129101.547674 $57450.1900 $0.4500
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Subtotal (Total Children Is Unduplicated) 7680 22786 223007.550224 $4549738.6800 $20.4000
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Total 28116 253525.535243 $5789073.9600 $22.8300
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Number of Children (Unduplicated) With at Least One Authorization 8344