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: 07-01-21 and 09-30-21 Date of Report: 10-13-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 10448 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 4 4 4.077778 $150.8800 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 266 273 3484.603174 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 270 277 3488.680952 $150.8800 $0.0400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 80 88 68.192248 $3307.3200 $48.5000
EVAL -96111 DEVELOPMENTAL EVALUATION 28 33 45.551598 $2277.5900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 178 179 313.300045 $15665.0000 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 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
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 6 7 14.000000 $1050.0000 $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 -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 7 7 14.000000 $777.0000 $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 3 4 8.000000 $600.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 1.222222 $62.3900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 1.444444 $73.7400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 1.194444 $60.9700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.127778 $6.5200 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 2.027778 $103.5200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 7.672222 $391.6700 $51.0500
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Subtotal (Total Children Is Unduplicated) 320 362 508.732779 $26530.7200 $52.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 10 17.338889 $86694.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 1.238888 $61.9400 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 1.633333 $375.6600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 599 739 667.513237 $33375.7900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 80 101 62.354335 $3117.7300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 90 100 80.199695 $2005.0100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1026 1134 1968.771119 $98438.4700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 69 79 84.794442 $4239.7100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 117 125 113.761106 $2844.0200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 841 956 1252.647613 $62632.3400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 74 76 69.679363 $3483.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 62 106 105.977775 $2649.4400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 333 371 503.468214 $25173.4000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 36 36 36.638887 $1831.9400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 38 37.722224 $943.0600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1069 1127 1427.700394 $71385.0100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 98 100 81.969838 $4098.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 110 114 115.471426 $2886.7800 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 5 5 28.928572 $723.2100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 70 76 488.211106 $24410.5600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 25.104762 $1255.2400 $50.0000
INTR -T1013 INTERPRETER 160 201 577.890475 $28894.5300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2332 2925 16862.437890 $168624.4800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 13 14 84.385714 $6028.5100 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 3.142857 $224.5300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 9.000000 $642.9600 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 7 7 49.000000 $3500.5600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 2.214286 $158.1900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 3 3 13.285714 $759.4100 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.000000 $195.0000 $65.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.266667 $577.6200 $456.0100
SENS -V5264 EARMOLD 1 1 0.633333 $11.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 17 69.533332 $4967.4700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 11.690477 $835.1700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.066667 $219.0900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 21.428571 $297.4300 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.666667 $24.6700 $37.0000
TRAV -TRAVS Travel by mile 882 1325 68696.287509 $30569.8400 $0.4500
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Subtotal (Total Children Is Unduplicated) 3952 9809 93580.055377 $679157.0600 $7.2600
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Total 10448 97577.469108 $705838.6600 $7.2300
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Number of Children (Unduplicated) With at Least One Authorization 4279