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: 07-01-19 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 57641 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 6 6 13.311112 $492.5100 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 850 1016 3719.341724 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 7 7 69.346032 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 52 54 5178.417464 $191601.4400 $37.0000
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Subtotal (Total Children Is Unduplicated) 910 1083 8980.416332 $192093.9600 $21.3900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 276 418 464.010551 $22504.5200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.027778 $114.5500 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 763 808 879.592064 $20661.6200 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.983333 $23.3000 $23.7000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 2 4.000000 $153.8800 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 5.166667 $438.3400 $84.8400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 2.511111 $288.7800 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 85 105 91.152889 $4557.6600 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 1597 1642 2837.434099 $141871.7000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 4.005479 $300.4100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 7 8.012328 $600.9300 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 2.006849 $150.5200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 2.175342 $163.1500 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 7 5.353425 $401.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 27 29 22.609884 $1254.8400 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 3.013698 $167.2600 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 1.500000 $83.2500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 59 59 93.041098 $6978.0700 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 30 30 52.021916 $3901.6500 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 19 19 16.039727 $1202.9600 $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 111 113 171.679450 $9528.2100 $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 49 53 96.079452 $7205.9600 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 6 7 72.971427 $3648.5700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 25.219047 $1260.9500 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.761110 $38.8500 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 4.511112 $230.3000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 58 66 80.400078 $4104.4300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 1.172222 $59.8400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 33 41 31.977093 $1632.4300 $51.0500
SCREEN-T1023 SCREENING 4 4 4.000000 $200.0000 $50.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 1 2 1.038889 $53.0400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 74 84 81.054037 $4137.8200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 11 11 11.000000 $490.0500 $44.5500
VISF -92499 VISION EVALUATION FUNCTIONAL 2 2 1.816666 $90.8300 $50.0000
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Subtotal (Total Children Is Unduplicated) 2996 3570 5115.338821 $240511.8100 $47.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 52 65 100.173137 $500866.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 6 7 10.247031 $512.3500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 19 25 46.003196 $2300.1600 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.022222 $144.8100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 8 8 7.466667 $1717.3400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2352 3299 4112.364307 $205618.7400 $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 484 540 448.114390 $11202.9100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3914 5883 21762.908442 $1088145.1500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 43 53 74.108731 $3705.4400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 545 806 2360.657140 $59016.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2386 3759 10994.915846 $549745.8000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 38 41 55.135710 $2756.7700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 219 473 1353.388889 $33834.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1451 2180 7189.916259 $359495.7400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 29 32 32.516665 $1625.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 70 162 553.297615 $13832.4300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3997 5656 15110.300192 $755514.7100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 61 68 74.486506 $3724.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 533 748 2037.012696 $50925.3100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 11 12 81.306349 $2032.6600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 9 9 43.979365 $2198.9700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 750 1039 15844.184122 $792209.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 34 37 339.680950 $16984.0500 $50.0000
INTR -T1013 INTERPRETER 567 808 5176.941827 $258847.0900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 8834 18077 221504.573592 $2215045.8500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 81 106 1439.442850 $102833.8000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 8.857143 $632.7600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 43 61 807.749999 $46203.3100 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 10.142857 $724.6100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 143 183 2174.829369 $155369.8400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.142857 $295.9700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 8 12 194.271428 $11104.5600 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 1.857143 $132.6700 $71.4400
RSPT -RSPT RESPITE 1 1 1.000000 $0.0000 $0.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 2 1.688889 $770.1400 $456.0000
SENS -V5264 EARMOLD 11 12 12.744444 $229.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 191 248 3215.830126 $229738.9000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 54.357142 $3883.2800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 5 107.571429 $6153.0800 $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 15 16 260.628571 $3617.5200 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 109 133 840.204359 $31087.5800 $37.0000
TRAV -TRAVS Travel by mile 2977 8372 1275725.028384 $567697.6500 $0.4500
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Subtotal (Total Children Is Unduplicated) 13625 52988 1594201.229463 $8093969.7300 $5.0800
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Total 57641 1608296.984616 $8526575.5000 $5.3000
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Number of Children (Unduplicated) With at Least One Authorization 15124