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: 01-01-20 and 03-31-20 Date of Report: 05-15-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 27321 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 0.833333 $30.8300 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 223 226 352.807938 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 120 121 7952.582537 $294245.5600 $37.0000
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Subtotal (Total Children Is Unduplicated) 337 348 8306.223808 $294276.3900 $35.4300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 99 115 107.681281 $5222.5500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 13 13.044444 $736.8800 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 235 235 249.714286 $5865.7900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 4.111111 $57.0200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 17 17 7.527777 $178.4100 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 3.787301 $34.3900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 19.930159 $554.6500 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.000000 $76.9400 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 12 14 12.477778 $1058.6200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 4 4 3.169863 $161.8900 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 9 10 9.533333 $159.2100 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.111111 $69.6900 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 6.839118 $307.7600 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 8 2.436378 $280.1900 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 21.804948 $1090.2600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 454 461 722.672452 $36133.6400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 3.500000 $262.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 40 41 64.027397 $4802.0500 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 11 11 17.510958 $1313.3300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 12 12 22.175342 $1663.1500 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 33 43 58.052057 $4353.8900 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 63 72 83.921333 $4657.6000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 2.008220 $111.4500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 372 375 594.270177 $44570.1700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 162 162 286.949613 $21521.2400 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 88 88 109.121922 $8184.1100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 485 489 721.326030 $40033.5200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 273 311 525.298633 $39397.3800 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 14.157142 $707.8500 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 38 39 19.913493 $1016.5900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 2.422222 $123.6500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 44 45 31.168416 $1591.1400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 341 357 214.586368 $10954.6200 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.116667 $5.9600 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 26 28 6.388890 $326.1600 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 2.000000 $102.1000 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 21 21 15.219559 $776.9600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 222 232 138.117279 $7050.9100 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 50 52 50.388889 $2519.4500 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.777778 $11.6700 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 9 8.372221 $427.4000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 14 14 13.196728 $673.7000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 390 415 240.743942 $12290.0200 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.183333 $9.3600 $51.0400
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 9 9 8.208219 $419.0300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 73 77 82.312698 $3667.0300 $44.5500
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Subtotal (Total Children Is Unduplicated) 2510 3858 4538.276866 $266305.9200 $58.6800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 86 93 88.663243 $443316.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 0.955556 $47.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 17 17 14.672222 $733.6100 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 4.666667 $334.1800 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 3.880953 $277.9200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 12 12 15.011111 $3452.5500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 869 1011 972.546139 $48627.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 178 200 173.053663 $4326.3500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1269 1390 2110.343547 $105517.2200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 11 11 3.923809 $196.1900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 189 203 224.422229 $5610.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 826 948 1136.190485 $56809.4600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 2 2 0.919047 $45.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 70 120 124.197228 $3104.9500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 515 558 736.929757 $36846.4600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 5 5 1.733333 $86.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 34 28.055556 $701.3900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1345 1421 1549.357521 $77467.7900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 6 6 1.277777 $63.8900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 190 202 218.073817 $5451.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 184 197 2042.820640 $51070.5100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 3 3 7.276190 $363.8100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5383 5753 37926.915891 $1896345.8700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 263 266 626.028567 $31301.4700 $50.0000
INTR -T1013 INTERPRETER 197 239 805.951715 $40297.6000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3453 4678 24077.926908 $240779.2700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 665 704 4207.239692 $300565.1500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 46 46 97.371429 $6956.2300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 345 365 2160.812706 $123598.4200 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 13 13 38.000000 $2173.6000 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.571429 $40.8200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 5.285714 $377.6100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 765 819 4434.819051 $316823.4900 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 30 30 58.976191 $4213.2700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 97 99 575.980953 $32923.0700 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 5 5 3.657143 $209.0500 $57.1600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 1.714286 $97.9900 $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 3 4 1.375038 $313.5000 $227.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.133334 $516.8300 $456.0300
SENS -V5264 EARMOLD 22 23 14.621919 $263.2000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1139 1223 7634.540481 $545411.5700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 68 69 116.016666 $8288.2600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 40 43 226.214287 $12939.4600 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 4 24.285714 $1734.9700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 9.000000 $642.9600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 78 81 484.790480 $6728.8800 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.357143 $4.9600 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 59 72 56.304761 $2083.3000 $37.0000
TRAV -TRAVS Travel by mile 1142 2130 120229.576170 $53502.1600 $0.4500
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Subtotal (Total Children Is Unduplicated) 7692 23115 213279.438158 $4473651.0200 $20.9800
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Total 27321 226123.938832 $5034233.3300 $22.2600
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Number of Children (Unduplicated) With at Least One Authorization 8263