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: 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 22849 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 2 2 11.866667 $439.0700 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 253 255 733.538889 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 38 38 3113.633333 $115204.4300 $37.0000
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Subtotal (Total Children Is Unduplicated) 293 295 3859.038889 $115643.5000 $29.9700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 111 127 88.772298 $4305.4600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 17.329050 $965.4000 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 78 82 87.908730 $2065.8500 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 184 186 185.366667 $4356.1200 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 8.216438 $119.8000 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 68 68 38.506471 $904.9100 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 13 9.066667 $88.7600 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 8 8 8.000000 $78.3200 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 11.066667 $317.8400 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 8 8 8.000000 $358.0800 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 33 33 29.872223 $409.5500 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 21 21 19.988889 $417.5700 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 9 7.722223 $347.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 11.244444 $1293.1100 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 25 30 45.466514 $2273.3300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 9 10 18.355556 $917.7800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 99 100 161.020167 $8051.0100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 21 39.511111 $2963.3300 $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 27.000000 $2025.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 12.000000 $900.0000 $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 31 31 54.686062 $3035.0700 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 9 9 16.011111 $888.6200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 290 293 556.345983 $41725.9700 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 245 245 462.024659 $34651.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 138 138 268.500000 $20137.5000 $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 48.126027 $3609.4500 $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 502 506 958.045984 $53171.5600 $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 217 233 448.931311 $33669.8500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 19 19 36.500000 $2737.5000 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 9.538096 $476.9100 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 56 59 21.888892 $1117.4400 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.216667 $11.0600 $51.0600
OCTH -97165 OT EVAL LOW COMPLEXITY 53 56 39.564460 $2019.7700 $51.0500
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.288889 $14.7500 $51.0500
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.161111 $8.2200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 36 37 23.449237 $1197.0700 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 1.138888 $58.1400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 236 244 203.121069 $10369.3300 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 4.209524 $214.9000 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 5 5 5.259524 $268.5000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 27 27 11.522220 $588.2000 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 21 24 13.217046 $674.7200 $51.0500
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 1.322222 $67.5000 $51.0500
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 22 22 13.086378 $668.0600 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 103 109 55.048175 $2810.2100 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 34 35 41.789682 $2089.4900 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 56 60 49.576982 $2530.9000 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 14 14 13.400000 $684.0700 $51.0500
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.038889 $1.9900 $51.0600
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 7.922222 $404.4300 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 236 259 134.181484 $6849.9600 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.243302 $63.4700 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 4.654262 $237.6000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 32 34 28.822222 $1471.3700 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 61 64 51.543584 $2296.2600 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 0.460578 $20.5200 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 21 22 121.060314 $6364.1500 $52.5700
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Subtotal (Total Children Is Unduplicated) 2227 3765 5190.429742 $313117.5100 $60.3300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 72 76 58.222753 $291113.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 21 21 30.780951 $1539.0400 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 7.903175 $544.2100 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 8 8 5.983410 $412.0200 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 38 38 37.058849 $8523.5000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 769 934 766.873662 $38343.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 92 118 85.030950 $4251.5500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 204 233 182.048101 $4551.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1156 1268 2022.847230 $101142.4300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 72 73 121.466671 $6073.3500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 133 146 152.001590 $3800.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 899 981 1263.473399 $63173.6000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 83 90 75.023014 $3751.1500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 72 111 106.475393 $2661.8700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 375 413 532.340085 $26617.0400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 38 38 44.679364 $2233.9700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 35 36.269447 $906.7400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1206 1267 1587.132149 $79356.6100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 96 101 94.550795 $4727.5500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 133 150 143.843652 $3596.0900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 6 6 36.285713 $907.1500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 81 87 1209.714281 $30242.8700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 146 183 708.262692 $35413.1300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4425 4836 31846.154070 $1592308.4700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 484 513 2153.337271 $107666.9200 $50.0000
INTR -T1013 INTERPRETER 176 203 562.727266 $28136.3600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2200 2812 14700.155921 $147001.6600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 631 684 4212.746800 $300958.8400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 14 16 40.238095 $2874.6200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 103 112 809.652380 $46312.1100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 7 7 45.571430 $2606.6800 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 23 25 77.002379 $5501.0700 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 44 53 236.068252 $16864.7500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 563 623 3331.657929 $238013.7100 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 10 10 15.914285 $1136.9200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 56 61 410.197619 $23446.9000 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 24.228571 $1384.9100 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 32 32 91.020634 $6502.5300 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 37 38 143.798413 $10272.9500 $71.4400
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 5 5 3.844445 $1753.0900 $456.0100
SENS -V5264 EARMOLD 14 14 16.699999 $300.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 901 981 5776.189239 $412651.2100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 21 23 91.952378 $6569.0900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 9.142857 $522.9700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 23 23 76.104761 $5436.9100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 53 54 265.137301 $18941.4100 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 18 18 146.023807 $2026.8100 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 3.142857 $43.6200 $13.8800
TRAV -TRAVS Travel by mile 872 1261 73098.910510 $32529.0100 $0.4500
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Subtotal (Total Children Is Unduplicated) 6572 18789 147495.886795 $3725646.6800 $25.2600
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Total 22849 156545.355426 $4154407.6800 $26.5400
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Number of Children (Unduplicated) With at Least One Authorization 7271