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: 01-01-21 and 03-31-21 Date of Report: 05-04-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 11184 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 222 235 737.840479 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 222 235 737.840479 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 82 94 76.140803 $3692.8400 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 203 204 208.857143 $4906.0500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.144444 $2.0000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.000000 $71.1000 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.144444 $1.3100 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.144444 $4.0200 $27.8200
AUDE -92585 AUD EVOKED RESPONSE (COMP) 1 1 1.000000 $84.8400 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.000000 $33.4000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $22.4000 $22.4000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.988889 $113.7200 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 18.560808 $928.0500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 290 291 477.270030 $23863.4900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.500000 $337.5000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 8 8 16.000000 $1200.0000 $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 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 9.005479 $499.8100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.500000 $787.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.250000 $12.7600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.016667 $0.8500 $51.1500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 3.472222 $177.2600 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.011111 $0.5700 $51.0000
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 7 7 4.105556 $209.5900 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 4.561111 $232.8400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.033333 $1.4800 $44.5100
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Subtotal (Total Children Is Unduplicated) 639 699 883.706484 $39930.5300 $45.1900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 10 12 15.474429 $77372.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.766667 $138.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 3.577777 $178.8900 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.144444 $33.2100 $229.9300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 603 762 673.367306 $33668.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 44 47 26.500737 $1325.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 115 125 113.797475 $2844.9600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1125 1219 1766.790093 $88339.4200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 35 37 44.099207 $2204.9600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 118 122 123.161903 $3079.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 775 883 1002.364713 $50118.2500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 42 42 65.802379 $3290.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 53 87 101.299998 $2532.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 449 491 676.570619 $33828.4600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 30 30 31.031746 $1551.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 40 51.366666 $1284.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1181 1229 1378.679358 $68933.9400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 52 53 55.394447 $2769.7400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 120 126 134.169046 $3354.2200 $25.0000
DSTT -DSTT DIRECT SERVICE COORDINATOR TRAVEL 1 1 1.933333 $0.0000 $0.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.392857 $34.8200 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 5.857143 $292.8600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 121 136 782.260318 $39113.0100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 15.085715 $754.2800 $50.0000
INTR -T1013 INTERPRETER 192 236 683.238339 $34161.9200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2364 3221 16284.963598 $162849.5700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 17 19 45.766668 $3269.5700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 7 7 12.725396 $727.8900 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 7.714286 $551.1100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 17 19 100.938094 $7211.0100 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.571429 $489.9400 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.988889 $225.4700 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.144444 $65.8500 $455.8600
SENS -V5264 EARMOLD 2 2 1.133333 $20.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 35 37 206.956349 $14784.9500 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 4 5 5.107937 $188.9900 $37.0000
TRAV -TRAVS Travel by mile 757 1243 64696.580714 $28789.9800 $0.4500
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Subtotal (Total Children Is Unduplicated) 4077 10250 89128.717852 $670443.9200 $7.5200
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Total 11184 90750.264815 $710374.4500 $7.8300
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Number of Children (Unduplicated) With at Least One Authorization 4552