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: 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 21190 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 5.377778 $198.9800 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 216 225 384.411911 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.857143 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 188 189 2157.031743 $79810.1700 $37.0000
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Subtotal (Total Children Is Unduplicated) 405 417 2552.678575 $80009.1400 $31.3400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 94 102 104.225669 $5054.9400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 14.000000 $790.8600 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 2.000000 $39.4200 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 193 193 206.734921 $4856.2000 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 5.155556 $71.5100 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 22 22 9.666666 $229.1000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 13.233334 $120.1600 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 9 9 10.348402 $288.0000 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 16 16 18.072222 $1533.2500 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 10 10 10.000000 $167.0000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 12.233334 $274.0300 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 6.057761 $272.6000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 2.789040 $320.7500 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 15 16 10.789498 $539.4800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 289 289 478.914787 $23945.7400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 12 12 20.505479 $1537.9100 $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 3 3 6.000000 $450.0000 $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 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 9 9 14.015221 $1051.1400 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 9 6.013700 $451.0100 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 41 42 72.086757 $4000.8100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 16 16 23.024809 $1277.8800 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 71 71 133.002740 $9975.2000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 184 187 354.043834 $26553.2900 $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 96 97 156.075346 $11705.6400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 241 243 424.308369 $23549.1200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 97 97 187.513698 $10407.0100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 225 300 544.202694 $40815.2200 $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 3 4 10.190477 $509.5300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 42 45 14.841857 $757.6800 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.150685 $7.6900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 1.172222 $59.8400 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.344444 $17.5800 $51.0400
OCTH -97166 OT EVAL MODERATE COMPLEXITY 25 25 26.648033 $1360.3900 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.027778 $1.4200 $51.0900
OCTH -97167 OT EVAL HIGH COMPLEXITY 226 237 125.681810 $6416.0500 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.194444 $9.9200 $51.0400
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.138889 $7.0900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 23 25 86.480746 $4414.8400 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 2 2 2.005556 $102.3900 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 14 15 13.194444 $673.5700 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 0.372222 $19.0000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 162 166 98.209360 $5013.5700 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 3 1.362710 $69.5700 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 3 0.475037 $24.2500 $51.0500
SCREEN-T1023 SCREENING 59 59 56.033334 $2801.6700 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 7.000000 $357.3500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 9 9 9.261111 $472.7800 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 269 280 160.796171 $8208.6400 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 5.695662 $290.7600 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 4.261111 $217.5300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 5 5 5.000000 $255.2500 $51.0500
SPCH -92524TLGT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.188889 $9.6400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 72 72 62.760949 $2796.0000 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.944444 $47.2200 $50.0000
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Subtotal (Total Children Is Unduplicated) 1905 2880 3709.991578 $217725.5500 $58.6900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 79 89 73.975268 $369876.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 5.733334 $286.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 11 7.505558 $375.2900 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 6.488889 $464.6700 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 15 17 30.888889 $7104.4500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 555 681 755.626372 $37781.3400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 32 33 21.323484 $1066.1900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 412 493 417.375151 $10434.4300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1065 1180 1878.963491 $93948.2100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 30 34 32.234922 $1611.7500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 141 150 167.455556 $4186.3900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 714 792 1009.598426 $50480.0000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 37 39 49.205552 $2460.2600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 51 77 103.057146 $2576.4400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 445 487 524.657928 $26232.8600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 25 26 20.938888 $1046.9400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 47 39.037303 $975.9400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1161 1202 1391.103583 $69555.2400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 54 58 59.430952 $2971.5500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 123 125 119.761112 $2994.0300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 139 192 1130.857155 $28271.3600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 17.636508 $881.8300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3976 4208 26759.778961 $1337988.9700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 308 323 1954.388890 $97719.4500 $50.0000
INTR -T1013 INTERPRETER 98 115 395.169049 $19758.4500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2348 3213 16657.946004 $166579.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 561 599 3075.089664 $219684.4200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 41 43 234.649205 $16763.3300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 227 248 1374.190472 $78603.7100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 6 6 20.421430 $1168.1000 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 6 6 65.714287 $4694.6200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 23 24 122.600000 $8758.5400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 635 672 3595.598301 $256869.5100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 29 31 161.384922 $11529.3400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 55 63 346.242856 $19791.2500 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 23.714286 $1355.5100 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 9 10 47.695236 $3407.3500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 22 25 120.218252 $8588.4000 $71.4400
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 0.236530 $53.9400 $228.0700
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 12.522223 $5710.1700 $456.0000
SENS -V5264 EARMOLD 14 14 17.865146 $321.5800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 958 1011 5767.830142 $412053.8300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 68 70 443.615868 $31691.9300 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 14 18 76.000001 $4347.2000 $57.2000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 6.285714 $359.5400 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 9 9 44.071429 $3148.4600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 42 43 213.110317 $15224.6100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 93 107 542.741807 $7533.2700 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.857143 $25.7800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 51 59 270.454362 $10006.8200 $37.0000
TRAV -TRAVS Travel by mile 777 1213 69002.905532 $30706.2900 $0.4500
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Subtotal (Total Children Is Unduplicated) 5975 17893 139220.153496 $3490547.1200 $25.0700
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Total 21190 145482.823649 $3788281.8200 $26.0400
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Number of Children (Unduplicated) With at Least One Authorization 6664