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 11234 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 255 258 1010.458136 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 258 261 1014.991469 $167.7300 $0.1700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 91 100 84.677670 $4106.8600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $55.7100 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.377778 $8.8800 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.377778 $55.8800 $23.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.783334 $18.4100 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.377778 $3.7000 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.377778 $10.8500 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.377778 $16.9100 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 2.377778 $32.6000 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 0.811111 $16.9400 $20.8900
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.0000 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 30 34 46.165677 $2308.2800 $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 -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
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 6 10.005479 $750.4100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 7 7 12.000000 $900.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 5.000000 $375.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 1 1 1.500000 $112.5000 $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 11.505479 $638.5600 $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 7 8 16.000000 $1200.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.316667 $16.1700 $51.0600
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.711111 $36.3000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 20 20 14.315082 $730.8000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.316667 $16.1700 $51.0600
PSTH -97163 PT EVAL HIGH COMPLEXITY 9 9 2.722223 $138.9700 $51.0500
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.366667 $18.7200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 5.366669 $273.9800 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 5.313492 $236.7200 $44.5500
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Subtotal (Total Children Is Unduplicated) 304 363 437.093006 $23014.8200 $52.6500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 14 20.166667 $100833.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 2.050000 $102.5000 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 3.400000 $782.0000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 704 886 726.772310 $36338.8100 $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 135 142 84.687633 $2117.2100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1187 1341 2221.323004 $111066.0900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 83 84 140.129364 $7006.4600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 119 136 110.701589 $2767.5400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 875 974 1247.332932 $62366.6500 $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 391 433 595.964738 $29798.1600 $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 1217 1271 1531.318634 $76565.8700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 91 93 89.215081 $4460.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 122 135 108.973813 $2724.3500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 67 70 488.614285 $24430.7300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 96 103 608.827776 $30441.4100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 5 6 25.815873 $1290.8000 $50.0000
INTR -T1013 INTERPRETER 158 181 527.151074 $26357.5500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2362 2947 16461.792664 $164617.8400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 30 188.059528 $13434.9600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 1 1 2.142857 $122.5700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 6.500000 $371.8000 $57.2000
OCCT -97530TLGT OT SESSION BY LICENSED OT 4 5 13.785714 $984.8500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 32 34 204.476189 $14607.7700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 1 1 8.142857 $465.4500 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 2.000000 $130.0000 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.800000 $364.8000 $456.0000
SENS -V5264 EARMOLD 2 2 0.755556 $13.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 37 38 289.495236 $20681.5400 $71.4400
TRAV -TRAVS Travel by mile 888 1266 69025.834518 $30716.4900 $0.4500
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Subtotal (Total Children Is Unduplicated) 4444 10610 95105.091796 $781479.3800 $8.2200
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Total 11234 96557.176271 $804661.9300 $8.3300
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Number of Children (Unduplicated) With at Least One Authorization 4758