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 10929 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 210 218 378.619848 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 5.857143 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 6 6 4.999999 $185.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 219 227 394.854768 $383.9700 $0.9700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 87 95 99.311895 $4816.6200 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 165 165 171.734921 $4034.0500 $23.4900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 2 2 3.000000 $254.5200 $84.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
EVAL -96111 DEVELOPMENTAL EVALUATION 14 15 10.773060 $538.6600 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 284 284 470.914787 $23545.7400 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 12.241096 $679.3800 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 3.013698 $167.2600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 10.505479 $583.0600 $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 5 6 10.505479 $787.9100 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.094444 $4.8200 $51.0300
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 3.372299 $172.1600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 1.500000 $76.5800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 3.720168 $189.9200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 3.000000 $133.6500 $44.5500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.944444 $47.2200 $50.0000
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Subtotal (Total Children Is Unduplicated) 587 623 833.631770 $37875.9400 $45.4300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 9 11.023136 $55115.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.166667 $108.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.411112 $170.5600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.466667 $337.3400 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 524 639 688.623632 $34431.2100 $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 303 330 256.570659 $6414.3200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1051 1163 1868.757935 $93437.9300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 30 34 32.234922 $1611.7500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 140 149 166.983334 $4174.5900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 708 786 999.198427 $49960.0000 $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 438 479 520.874594 $26043.6900 $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 1153 1193 1380.798028 $69039.9700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 54 58 59.430952 $2971.5500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 118 120 116.216668 $2905.4200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 6.142857 $153.5700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 6 6 17.636508 $881.8300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 148 154 991.331749 $49566.5700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 21 135.085713 $6754.3000 $50.0000
INTR -T1013 INTERPRETER 96 111 388.946827 $19447.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2348 3213 16657.946004 $166579.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 21 78.553967 $5611.8800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 44.714286 $2557.6600 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 10.142857 $724.6100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 25 26 154.761906 $11056.1800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.142857 $295.9700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.857143 $163.3100 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 1.857143 $132.6700 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.055556 $25.3500 $456.3600
SENS -V5264 EARMOLD 1 1 0.055556 $1.0000 $18.0100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 41 43 200.819047 $14346.5100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 9.642857 $688.8900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 16.571429 $947.8800 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.857143 $132.6700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 6.857143 $95.1800 $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) 3890 10079 94344.657548 $675723.8300 $7.1600
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Total 10929 95573.144086 $713983.7400 $7.4700
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Number of Children (Unduplicated) With at Least One Authorization 4372