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: 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 10277 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 230 232 305.057156 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 230 232 305.057156 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 97 110 82.976828 $4024.3600 $48.5000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.911111 $21.4100 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.577778 $60.5800 $23.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.911111 $21.4100 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.305555 $12.7800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.911111 $26.1700 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.911111 $40.7800 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.911111 $12.4900 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.911111 $19.0300 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.355556 $16.0000 $45.0100
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.355556 $40.8900 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 27.287366 $1364.3700 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 132 134 210.596804 $10529.8500 $50.0000
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
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 1.055556 $53.8900 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 15 15 21.167461 $1080.6000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 8 8 3.994444 $203.9100 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 4.961110 $253.2600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 3 4 3.155556 $161.0900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 6.638889 $295.7600 $44.5500
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Subtotal (Total Children Is Unduplicated) 304 359 432.323696 $22167.6400 $51.2800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 12 16.988889 $84944.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 5.355556 $267.7800 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.355556 $24.4900 $68.8700
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $230.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 645 808 699.811408 $34990.7400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 116 140 100.792904 $5039.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 116 127 81.203110 $2030.1000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1129 1217 2079.016481 $103950.8900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 71 79 128.640478 $6432.0300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 90 93 109.600001 $2740.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 817 915 1312.918256 $65645.9400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 71 74 93.726989 $4686.3700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 53 85 93.305557 $2332.6400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 351 395 648.597625 $32429.9200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 48 49 65.122227 $3256.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 19 35 37.377778 $934.4500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1076 1122 1546.094855 $77304.8000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 104 107 126.287307 $6314.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 96 99 115.865079 $2896.6300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 84 91 692.819043 $34640.9800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 2.355556 $117.7800 $50.0000
INTR -T1013 INTERPRETER 138 155 512.226678 $25611.3300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2301 2806 16957.482852 $169574.9700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 16 16 114.857141 $8205.4100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 3 3 26.928571 $1540.3200 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 0.642857 $36.7700 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 119.933333 $8568.0400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 24 26 159.030950 $11361.1800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.066667 $290.5300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 4.714286 $269.4700 $57.1600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 19 19 133.742856 $9554.6000 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 8.571429 $118.9700 $13.8800
TRAV -TRAVS Travel by mile 838 1195 82188.331800 $36573.8100 $0.4500
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Subtotal (Total Children Is Unduplicated) 4109 9686 108187.764075 $742915.6000 $6.8700
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Total 10277 108925.144927 $765083.2400 $7.0200
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Number of Children (Unduplicated) With at Least One Authorization 4404