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: 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 10661 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 236 239 319.819042 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 138.000000 $5106.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 237 240 457.819042 $5106.0000 $11.1500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 98 107 101.258065 $4911.0100 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 5 5 5.000000 $117.4500 $23.4900
EVAL -96111 DEVELOPMENTAL EVALUATION 21 24 33.173896 $1658.7000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 9 18.000000 $900.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 249 252 444.769113 $22238.4600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.164384 $162.3300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 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 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
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.833333 $41.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 1.527778 $77.9900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 10.505556 $536.3100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 1.166667 $59.5600 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 4.366666 $222.9200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 13.611111 $694.8500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
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Subtotal (Total Children Is Unduplicated) 414 459 697.887527 $35703.1500 $51.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 7 8.416667 $42083.5000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.011111 $50.5600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 4.050000 $202.5000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.544444 $125.2100 $229.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 542 664 587.504796 $29375.3400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 73 93 65.273894 $3263.7000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 101 109 73.977788 $1849.4700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1022 1108 1852.372604 $92618.5800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 54 61 91.364283 $4568.2100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 132 139 122.173818 $3054.3700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 802 895 1252.438077 $62621.8300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 79 80 100.903567 $5045.1600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 58 98 90.642065 $2266.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 370 412 591.197217 $29559.8700 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 47 47 68.081350 $3404.0800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 47 56.526186 $1413.1500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1085 1129 1480.794042 $74039.6800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 94 96 105.600795 $5280.0500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 128 133 131.535321 $3288.3900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 12.000000 $300.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 68 70 494.155547 $24707.7900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 26.533333 $1326.6700 $50.0000
INTR -T1013 INTERPRETER 144 170 656.969764 $32848.4800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2490 3206 18683.558852 $186835.6200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 24 25 108.795238 $7772.3300 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 0.822222 $58.7400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.428571 $81.7200 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 13 13 75.304761 $5379.7700 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $456.0000 $456.0000
SENS -V5264 EARMOLD 1 1 0.544444 $9.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 25 27 147.780952 $10557.4800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 9.285714 $663.3700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.000000 $142.8800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 1 1 3.428571 $47.5900 $13.8800
TRAV -TRAVS Travel by mile 878 1307 65826.810989 $29292.9300 $0.4400
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Subtotal (Total Children Is Unduplicated) 3998 9962 92736.826983 $665046.8100 $7.1700
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Total 10661 93892.533552 $705855.9700 $7.5200
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Number of Children (Unduplicated) With at Least One Authorization 4339