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: 01-01-22 and 03-31-22 Date of Report: 04-16-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 23896 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 3 3 4.533333 $167.7300 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 264 267 1049.201786 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 42 42 2828.372223 $104649.7800 $37.0000
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Subtotal (Total Children Is Unduplicated) 309 312 3882.107342 $104817.5100 $27.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 94 103 86.174474 $4179.4600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 15 15 13.376256 $745.1900 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 25 25 23.900000 $561.6500 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 369 371 386.331746 $9078.8000 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 2.816667 $41.0700 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 42 42 29.961179 $704.1000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 6.599999 $64.6100 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 2.000000 $19.5800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 10.377777 $298.0500 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 4 3.377778 $151.1900 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 4.127778 $350.2000 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 4 4 3.155556 $161.1600 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 23 23 20.177777 $276.6400 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 21 21 32.692062 $682.9400 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 8.105555 $364.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 6 5.844444 $672.1100 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 31 36 49.165677 $2458.2800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 8 14.355556 $717.7800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 115 116 181.593454 $9079.6700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 22 39.694444 $2977.0800 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 18 18 29.033333 $2177.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 14 14 28.000000 $2100.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 15 15 23.027701 $1727.0800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 32 34 59.530126 $3303.9200 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 10 10 16.230289 $900.7800 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 292 294 557.060269 $41779.5400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 246 246 462.243837 $34668.2700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 137 137 266.500000 $19987.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 36 37 72.000000 $5400.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 29 29 50.010959 $3750.8200 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 115 115 202.026029 $15151.9400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 501 505 959.845984 $53271.4600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 163 163 298.031508 $16540.7400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 216 232 446.931311 $33519.8500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 36.500000 $2737.5000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.633333 $81.6700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 18.371428 $918.5800 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 51 51 28.622221 $1461.1600 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.383333 $19.5700 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 15 17 15.066666 $769.1500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 39 39 23.275496 $1188.2200 $51.0500
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 315 331 224.022830 $11436.3700 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 29 29 10.622223 $542.2700 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.422222 $21.5500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 9 9 6.922222 $353.3800 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 26 26 15.683333 $800.6300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 143 151 86.408807 $4411.1800 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.366667 $18.7200 $51.0500
SCREEN-T1023 SCREENING 29 32 39.428571 $1971.4300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 29 31 25.940476 $1324.2600 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 9 9 9.111111 $465.1200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 296 311 175.617795 $8965.2900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.758829 $38.7400 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.900000 $45.9500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 3.621918 $184.9000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 51 54 45.994444 $2348.0100 $51.0500
SPCH -92524GT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.155556 $7.9400 $51.0600
SPCH -92524TLGT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 74 76 70.244468 $3129.4000 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.109589 $4.8800 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.158904 $7.0800 $44.5800
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 4 4 24.828571 $1305.2400 $52.5700
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Subtotal (Total Children Is Unduplicated) 2482 3923 5286.470538 $314327.1000 $59.4600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 71 77 75.698011 $378490.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.533333 $26.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 18 18 16.861112 $843.0600 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 25 25 47.267092 $3254.8100 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 35 36 36.040107 $8289.2200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 764 963 791.203222 $39560.3800 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 93 118 81.903171 $4095.1600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 206 236 179.484669 $4487.1300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1203 1357 2235.226178 $111761.2400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 83 84 140.129364 $7006.4600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 120 137 111.201589 $2780.0400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 885 984 1256.110709 $62805.5300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 99 106 124.108733 $6205.4500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 66 111 101.766669 $2544.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 396 438 603.862358 $30193.0500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 35 37 37.700001 $1885.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 17 30 22.383330 $559.5800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1230 1285 1546.941648 $77347.0200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 91 93 89.215081 $4460.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 123 136 109.251591 $2731.3000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.857143 $21.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 155 171 1453.571433 $36339.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 68 71 491.547618 $24577.3900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4666 5103 32337.732571 $1616885.9800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 436 470 2068.761120 $103438.0200 $50.0000
INTR -T1013 INTERPRETER 178 204 576.355836 $28817.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2362 2949 16473.792664 $164737.8400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 724 793 4388.096829 $313485.5600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 17 19 89.857142 $6419.3900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 136 144 970.500009 $55512.5700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 8 9 33.952381 $1942.0700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 18 20 61.706350 $4408.3000 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 67 79 286.638098 $20477.4400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 633 697 3627.198416 $259126.9500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 14 15 93.833332 $6703.4600 $71.4400
PHY -97110HM PT SESSION BY PT ASST 64 72 438.214290 $25048.3000 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 10.590476 $605.3500 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 17 18 70.690475 $5050.1300 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 41 42 220.725395 $15768.5900 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.000000 $130.0000 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 1.011111 $461.0600 $456.0000
SENS -V5264 EARMOLD 12 13 12.744445 $229.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 996 1093 6263.917070 $447494.1800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 20 22 119.990475 $8572.1200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 23.000001 $1315.5900 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 21 22 164.138096 $11726.0200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 51 53 267.753970 $19128.3500 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 25 25 129.414285 $1796.2700 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.466667 $62.0000 $13.8800
TRAV -TRAVS Travel by mile 888 1269 69062.405947 $30732.7700 $0.4500
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Subtotal (Total Children Is Unduplicated) 6905 19661 147354.351613 $3960681.6000 $26.8800
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Total 23896 156522.929493 $4379826.2100 $27.9800
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Number of Children (Unduplicated) With at Least One Authorization 8082