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: 04-01-20 and 06-30-20 Date of Report: 07-20-20 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 26953 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 0.166667 $6.1700 $37.0100
SCONLY-SCONLY *SERVICE COORDINATION ONLY 287 295 498.885981 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 9.714286 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 572 575 16055.831763 $594065.7900 $37.0000
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Subtotal (Total Children Is Unduplicated) 835 872 16564.598697 $594071.9600 $35.8600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 101 118 101.413794 $4918.5500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 15.127778 $854.5700 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 313 313 352.181746 $8272.7500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 4.016666 $55.7100 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 18 19 11.433333 $270.9700 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 7.197488 $65.3500 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 10 11 7.224885 $201.0700 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 17 17 19.027777 $1614.3100 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 2.038889 $104.1300 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 14.118341 $235.7800 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 2.088888 $46.7900 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 4.852283 $218.3500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 2.283410 $262.5900 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 16 16 8.203883 $410.2000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 337 341 535.412114 $26770.6000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 14 23.505479 $1762.9100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 12 12 21.011111 $1575.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 10 10 15.015221 $1126.1400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 9 7.013700 $526.0100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 32 34 57.721004 $3203.5200 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 12 12 16.024809 $889.3800 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 73 73 136.502740 $10237.7000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 183 186 352.043834 $26403.2900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 33 34 55.526026 $4164.4500 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 26 26 50.005479 $3750.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 10 10 18.002740 $1350.2000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 95 96 154.075346 $11555.6400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 246 248 434.264337 $24101.6700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 96 96 185.513698 $10296.0100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 227 302 548.228917 $41117.1800 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 9.571428 $478.5700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 7 11.390477 $569.5300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 42 44 9.278091 $473.6400 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 2.172222 $110.8900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 40 40 26.697338 $1362.9000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 331 344 169.039154 $8629.4700 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 0.538889 $27.5100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 28 29 82.763016 $4225.0600 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 2 2 2.005556 $102.3900 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.061111 $105.2200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 21 21 19.556763 $998.3700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 216 224 117.606895 $6003.8400 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 3 2.084932 $106.4300 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.083333 $4.2500 $51.0300
SCREEN-T1023 SCREENING 40 42 35.166666 $1758.3300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 15 15 18.642857 $951.7200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 15 15 10.898248 $556.3500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 390 410 211.182376 $10780.8800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.544444 $129.8900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 10 10 8.444445 $431.0900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 72 73 68.221559 $3039.2700 $44.5500
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Subtotal (Total Children Is Unduplicated) 2294 3371 4006.025516 $229632.6700 $57.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 98 109 92.690040 $463449.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 1.566666 $78.3300 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 20 20 15.800000 $790.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 4.750000 $340.1500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 16 16 22.694445 $5219.7400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 601 745 837.457588 $41872.9200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 29 30 17.040151 $852.0200 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 396 474 393.331011 $9833.3300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1378 1544 2038.748404 $101937.3800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 15 17 19.538888 $976.9400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 206 221 262.992463 $6574.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 841 978 1102.662301 $55133.1200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 6 7 6.627778 $331.3900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 73 118 113.151196 $2828.8000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 528 568 705.473021 $35273.6700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 8 8 7.494444 $374.7200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 23 38 29.777777 $744.4400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1487 1555 1528.392859 $76419.6700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 15 15 16.555555 $827.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 190 201 207.559525 $5189.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 218 283 2084.269823 $52106.8000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 6.650000 $332.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5365 5776 34424.186011 $1721209.4600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 171 182 1336.342857 $66817.1800 $50.0000
INTR -T1013 INTERPRETER 113 133 506.832539 $25341.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3248 4380 20825.419802 $208254.2300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 742 801 4204.323824 $300357.0000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 35 37 215.684920 $15408.5400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 313 350 1732.111102 $99076.8200 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 11 11 86.142858 $4927.3700 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 6 6 34.604762 $2472.1600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 782 829 4046.473803 $289080.2600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 17 18 81.147618 $5797.2100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 96 107 520.499316 $29751.7300 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 20.857143 $1192.1900 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 10.819047 $772.9100 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 6 6 20.752381 $1482.5600 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 1.295129 $295.2800 $227.9900
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 7.700000 $3511.2000 $456.0000
SENS -V5264 EARMOLD 21 21 16.900685 $304.2100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1163 1250 6968.671025 $497841.9900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 53 54 354.876186 $25352.3700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 20 27 115.571431 $6610.6800 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 0.857143 $61.2300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 15 15 76.878571 $5492.2100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 106 120 553.173810 $7678.0600 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.928571 $26.7700 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 62 73 416.289286 $15402.7000 $37.0000
TRAV -TRAVS Travel by mile 964 1541 108270.140881 $48180.2100 $0.4500
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Subtotal (Total Children Is Unduplicated) 7391 22710 194365.704636 $4244184.6400 $21.8400
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Total 26953 214936.328849 $5067889.2600 $23.5800
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Number of Children (Unduplicated) With at Least One Authorization 8324