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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 11187 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 1 1 0.788889 $29.1900 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 296 300 612.942864 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 44.000000 $1628.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 298 302 657.731753 $1657.1900 $2.5200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 95 108 81.993020 $3976.6600 $48.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.5000 $23.5000
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $13.7100 $13.7100
EVAL -96111 DEVELOPMENTAL EVALUATION 18 20 27.221003 $1361.0500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 177 180 299.541879 $14977.0900 $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
IPDEI -T1024GNUK 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 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 16.142857 $895.9300 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 8.142857 $610.7200 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.142857 $7.1500 $50.0200
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 0.716667 $35.8400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 3 2.144444 $109.4700 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.411111 $72.0400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 7.644987 $390.2800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 10 6.433333 $328.4200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 11.531746 $588.7000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.455556 $20.3000 $44.5500
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Subtotal (Total Children Is Unduplicated) 334 385 504.522317 $26035.9800 $51.6100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 9 11 15.633333 $78166.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 2.488889 $124.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 7.288889 $364.4500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $68.8600 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.488889 $112.4500 $230.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 622 769 663.925974 $33196.4500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 101 123 90.699252 $4534.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 125 137 87.566999 $2189.2000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1110 1231 2087.043060 $104352.1700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 77 91 112.661903 $5633.0900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 117 125 120.156351 $3003.9200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 849 957 1259.800001 $62990.0200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 95 96 123.867462 $6193.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 54 95 67.551582 $1688.7800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 390 420 556.225004 $27811.2500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 56 59 66.963493 $3348.1800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 43 42.088886 $1052.2200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1191 1259 1591.923784 $79596.2000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 110 115 115.791263 $5789.5300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 117 121 113.284924 $2832.1300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.678571 $216.9700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 117 124 849.574604 $42478.7600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 18.498413 $924.9200 $50.0000
INTR -T1013 INTERPRETER 160 173 603.540962 $30177.0500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2542 3191 17177.824675 $171778.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 17 97.149999 $6940.4200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 3.590476 $256.5000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 1.857143 $106.2300 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 107.428571 $7674.7000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 16 17 88.142857 $6296.9300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 3 3 6.109524 $436.4700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 2 6.571429 $375.6200 $57.1600
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 0.488889 $8.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 29 29 138.698412 $9908.6200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 6 13.685714 $977.7100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.533333 $180.9800 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 11.714286 $162.5900 $13.8800
TRAV -TRAVS Travel by mile 882 1263 70440.545051 $31346.0500 $0.4500
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Subtotal (Total Children Is Unduplicated) 4400 10500 96706.082847 $734207.7200 $7.5900
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Total 11187 97868.336917 $761900.9000 $7.7800
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Number of Children (Unduplicated) With at Least One Authorization 4749