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: 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 10074 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 203 203 724.293642 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 204 204 726.260309 $72.7700 $0.1000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 90 98 93.126299 $4516.6200 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 90 90 97.142857 $2281.8900 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.116667 $5.9600 $51.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $16.7000 $16.7000
EVAL -96111 DEVELOPMENTAL EVALUATION 26 28 26.563622 $1328.1800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 5.000000 $250.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 305 309 553.397358 $27669.8600 $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 3 3 3.955556 $219.5400 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 0.002740 $0.1500 $54.6700
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
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 14.233333 $726.6100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.172222 $8.7900 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.427778 $72.8900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 3.483333 $177.8200 $51.0500
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Subtotal (Total Children Is Unduplicated) 551 593 869.873483 $42107.8300 $48.4100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 11 12.127778 $60639.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.733333 $36.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 3.922223 $196.1200 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 572 743 721.278915 $36064.0500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 40 46 39.498050 $1974.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 114 127 89.010302 $2225.2900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 913 984 1697.872979 $84893.6500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 48 50 57.502384 $2875.1300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 113 117 121.155554 $3028.8900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 712 774 1035.970240 $51798.5300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 51 53 78.863487 $3943.1500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 45 64 64.305555 $1607.6400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 354 384 601.215879 $30060.8400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 39 39 49.307934 $2465.3900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 33 42.516669 $1062.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1076 1114 1438.918253 $71945.9200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 49 50 56.087302 $2804.3700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 117 122 119.626186 $2990.6500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 3.142857 $78.5700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 75 80 535.566659 $26778.3500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 33.692858 $1684.6400 $50.0000
INTR -T1013 INTERPRETER 158 194 609.714870 $30485.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2298 3026 17303.487862 $173034.9700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 17 109.163489 $7798.6400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 12.285715 $877.6900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.285714 $473.9400 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 13.142857 $938.9300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 10 10 96.142856 $6868.4600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 2.285714 $130.6500 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 24 210.752380 $15056.1500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.142857 $438.8500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.285714 $130.7400 $57.2000
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 14.000000 $1000.1600 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 784 1192 64513.880334 $28708.6800 $0.4500
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Subtotal (Total Children Is Unduplicated) 3634 9277 89704.885759 $655135.2400 $7.3000
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Total 10074 91301.019551 $697315.8400 $7.6400
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Number of Children (Unduplicated) With at Least One Authorization 4039