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: 04-01-21 and 06-30-21 Date of Report: 07-15-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 11120 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 237 244 263.759519 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 97.000000 $3589.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 239 246 360.759519 $3589.0000 $9.9500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 100 109 88.446803 $4289.6700 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 144 144 154.159295 $3621.2000 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $13.8700 $13.8700
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 11.428571 $969.6000 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.250000 $12.7700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.144444 $2.4100 $16.7000
EVAL -96111 DEVELOPMENTAL EVALUATION 22 25 33.236910 $1661.8500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 11 21.000000 $1050.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 266 268 458.268723 $22913.4400 $50.0000
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 6 6 9.005479 $675.4100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 15.005479 $832.8100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.500000 $787.5000 $75.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 16 16 6.700000 $342.0400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.177777 $9.0700 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 4.616665 $235.6700 $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 0.138889 $6.1900 $44.5500
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Subtotal (Total Children Is Unduplicated) 576 627 837.367923 $38969.4300 $46.5400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 15 21.516666 $107583.0000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 2.366667 $118.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 7.166667 $358.3400 $50.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 574 745 649.738924 $32487.0400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 73 95 70.366751 $3518.3500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 98 106 69.994455 $1749.8900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1041 1159 1765.865491 $88293.3200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 55 58 80.280951 $4014.0500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 112 123 118.536514 $2963.4300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 814 922 1152.621042 $57631.1000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 61 67 79.926582 $3996.3100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 55 91 107.297617 $2682.4400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 366 398 492.176986 $24608.8600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 41 43 58.387697 $2919.3800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 33 44.515078 $1112.8800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1183 1240 1488.822236 $74441.1700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 76 81 82.920629 $4146.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 124 134 154.444448 $3861.1200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.288889 $21.1800 $73.3200
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 109 113 631.053975 $31552.7000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 47.269049 $2363.4600 $50.0000
INTR -T1013 INTERPRETER 155 178 729.665004 $36483.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2409 3264 16713.340154 $167133.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 27 107.655557 $7690.9200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 4.500000 $321.4800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 20.428572 $1168.5100 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 19 19 73.400001 $5243.7000 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 31 31 139.388891 $9957.9300 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 11.714286 $836.8700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 5.142857 $367.4100 $71.4400
TRAV -TRAVS Travel by mile 819 1281 68238.661893 $30366.2100 $0.4500
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Subtotal (Total Children Is Unduplicated) 4014 10247 93171.454529 $710448.0200 $7.6300
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Total 11120 94369.581971 $753006.4500 $7.9800
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Number of Children (Unduplicated) With at Least One Authorization 4457