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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 10950 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 1.966667 $72.7700 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 237 247 309.347615 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 92.400000 $3418.8000 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 242 252 403.714282 $3491.5700 $8.6500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 81 88 67.368852 $3267.3900 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 210 211 217.858729 $5117.5000 $23.4900
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 2.000000 $169.6800 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $16.7000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
EVAL -96111 DEVELOPMENTAL EVALUATION 25 28 28.874505 $1443.7300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 310 313 565.444826 $28272.2300 $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 0.005479 $0.4100 $75.2900
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 6.918645 $383.9800 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 1.002740 $55.6500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 0.500000 $37.5000 $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 9 9 15.013699 $833.2600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 8 16.500000 $1237.5000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 1.571429 $78.5700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.227778 $11.6300 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 13 6.972680 $355.9600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 3.772223 $192.5800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 5.133334 $262.0600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 7.142857 $318.2200 $44.5500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.300000 $15.0000 $50.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 677 728 992.107776 $45117.5400 $45.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 14.538508 $72692.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.833333 $91.6700 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.044444 $10.2100 $229.7700
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 577 724 672.346988 $33617.4100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 39 45 31.209954 $1560.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 120 142 89.218828 $2230.5100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1035 1137 1832.743614 $91637.2100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 37 40 37.680955 $1884.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 126 134 136.963486 $3424.0700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 684 768 961.332533 $48066.6100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 40 40 42.446032 $2122.3000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 53 78 89.795242 $2244.8900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 451 476 545.077004 $27253.9400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 37 37 40.685717 $2034.3000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 35 35.500001 $887.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1162 1207 1370.406354 $68520.3600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 51 52 52.289680 $2614.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 116 123 119.754759 $2993.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.142857 $78.5700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 2.272222 $113.6100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 139 146 906.695239 $45334.7800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 13 73.800000 $3690.0000 $50.0000
INTR -T1013 INTERPRETER 164 196 496.362492 $24818.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2343 3191 15905.916682 $159059.1700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 30 175.031743 $12504.2900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 18.857144 $1347.1500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 6 7 38.571428 $2206.2900 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 5.571429 $318.6800 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 25 25 111.142857 $7940.0500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.428571 $316.3800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.285714 $130.6500 $57.1600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.500000 $228.0000 $456.0000
SENS -V5264 EARMOLD 1 1 0.500000 $9.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 41 258.114287 $18439.6800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 21.285714 $1520.6600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 16.142857 $923.3700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 2.285714 $163.2900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 5.142857 $71.3800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 12 13 19.500001 $721.5000 $37.0000
TRAV -TRAVS Travel by mile 765 1232 66200.588337 $29459.2700 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3967 9970 90342.005577 $673280.3000 $7.4500
-------------------------------------------------------------------------------------------------------------------------------------
Total 10950 91737.827635 $721889.4100 $7.8700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 4455