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: 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 11217 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 3 3 3.311112 $122.5100 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 213 216 981.303968 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 76.000000 $2812.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 217 220 1060.615080 $2934.5100 $2.7700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 89 99 78.374047 $3801.1500 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 94 94 92.577321 $2174.6400 $23.4900
EVAL -96111 DEVELOPMENTAL EVALUATION 15 18 20.244293 $1012.2200 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 3 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 276 277 459.684705 $22984.2100 $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 2 2 4.000000 $222.0000 $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
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.305556 $66.6500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 13 14 7.088890 $361.8900 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 4 2.477778 $126.4900 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 15 16 6.011113 $306.8800 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.466667 $20.7900 $44.5500
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Subtotal (Total Children Is Unduplicated) 519 570 754.235849 $36637.8700 $48.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 9 15.727778 $78639.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 4 4 5.744444 $287.2200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.005479 $0.3900 $71.8900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 625 783 689.991509 $34499.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 46 49 31.956292 $1597.8300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 114 124 81.915729 $2047.9100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1068 1156 1873.477367 $93673.8300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 47 49 68.636508 $3431.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 139 141 150.755553 $3768.8800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 861 968 1319.742438 $65987.0400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 49 49 47.261111 $2363.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 72 118 116.338889 $2908.4700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 363 400 562.940479 $28147.0400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 36 36 50.253965 $2512.6900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 29 53 34.888883 $872.2100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1191 1234 1614.771826 $80738.6100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 63 64 72.326984 $3616.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 147 153 157.504759 $3937.6100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 2 9.321428 $233.0400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 99 106 617.990469 $30899.5500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 5 37.571428 $1878.5700 $50.0000
INTR -T1013 INTERPRETER 189 237 876.453417 $43822.6800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2548 3322 17753.976719 $177539.8200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 21 22 98.599997 $7043.9800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 30.642857 $1752.7700 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 12 13 56.042856 $4003.7000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.285714 $244.9700 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.011111 $65.7200 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 20 92.793650 $6629.1900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.357142 $811.3600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.000000 $142.8800 $71.4400
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 2 3 0.642858 $23.7800 $37.0000
TRAV -TRAVS Travel by mile 845 1293 66763.776302 $29709.8800 $0.4400
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Subtotal (Total Children Is Unduplicated) 4087 10427 93253.705941 $714517.4900 $7.6600
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Total 11217 95068.556870 $754089.8800 $7.9300
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Number of Children (Unduplicated) With at Least One Authorization 4488