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: 04-01-22 and 06-30-22 Date of Report: 08-08-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 25145 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 12.821429 $474.3900 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 287 298 419.016663 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 50 50 3994.322222 $147789.9200 $37.0000
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Subtotal (Total Children Is Unduplicated) 338 350 4426.160314 $148264.3100 $33.5000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 123 141 114.817879 $5568.6400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 15 15 13.300000 $740.9400 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 177 197 197.000000 $4629.5000 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 227 228 227.757143 $5352.2900 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 8 8 6.977777 $101.7300 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 41 41 22.450001 $527.5800 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 4.455555 $43.6200 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 3.000000 $29.3700 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 15 15 10.100000 $290.0700 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 3.000000 $134.2800 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 3.000000 $254.5200 $84.8400
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 22 22 16.772222 $229.9500 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 17 17 19.619048 $409.8400 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 6.088889 $274.0000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 13 9.342086 $1074.3500 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 20 25 35.737139 $1786.8600 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 7 14.000000 $700.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 74 74 108.571158 $5428.5600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 20 27 57.928571 $4344.6500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 14 24.011111 $1800.8300 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 20 20 35.522222 $2664.1700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 6 6 11.000000 $825.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 10.011111 $750.8300 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 11 11 17.022222 $1276.6700 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 8 26.357142 $1976.7900 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 23 23 40.527626 $2249.2900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 13 13 25.000000 $1387.5000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 308 313 573.572662 $43017.9800 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 296 297 561.042347 $42078.1700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 102 103 199.066667 $14930.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 44 45 84.000000 $6300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 84 85 161.508220 $12113.1100 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 94 94 166.276516 $12470.7400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 469 471 893.000516 $49561.5400 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 253 253 474.211872 $26318.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 201 217 424.000000 $31800.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 80 87 171.502740 $12862.7000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.000000 $50.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 10.295238 $514.7700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 75 76 33.940327 $1732.6700 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.255556 $13.0500 $51.0600
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 0.833333 $42.5400 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 82 98 81.111113 $4140.7300 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 2 2 1.884921 $96.2200 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 26 26 17.512783 $894.0200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 229 232 164.294114 $8387.2200 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 5 5 2.750000 $140.3900 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.188889 $9.6400 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 12.897619 $658.4200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 45 45 14.338737 $732.0000 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.111111 $5.6700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 33 39 26.020852 $1328.3600 $51.0500
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 20 21 23.320537 $1190.5200 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 2 2 1.388889 $70.9000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 126 129 53.423440 $2727.2700 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.411111 $20.9900 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
SCREEN-T1023 SCREENING 31 32 30.894445 $1544.7300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 74 88 77.897979 $3976.6900 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 8 8 8.000000 $408.4000 $51.0500
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 12 12 13.549999 $691.7200 $51.0500
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.161111 $8.2200 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 237 245 109.736497 $5602.0500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 2.841018 $145.0300 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.494444 $76.2900 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.717123 $36.6100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 27 27 21.555556 $1100.4100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 70 71 38.664763 $1722.5100 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 2.000000 $89.1000 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 27.714286 $1456.9400 $52.5700
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Subtotal (Total Children Is Unduplicated) 2517 4133 5575.756233 $337389.3600 $60.5100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 84 92 93.568754 $467844.5000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 35 35 34.261111 $1713.0600 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 13 14 11.350794 $781.6100 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 35 35 37.500793 $8625.1800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 831 1029 849.592199 $42479.8300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 90 103 60.940926 $3047.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 213 251 169.554847 $4238.9100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1216 1338 2133.793242 $106689.6000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 75 85 133.273808 $6663.6800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 104 107 118.377775 $2959.4400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 948 1074 1320.504749 $66025.1800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 78 79 63.682537 $3184.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 60 102 103.012698 $2575.3200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 401 462 620.923996 $31046.1500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 49 52 54.936507 $2746.8200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 49 38.955552 $973.8800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1244 1297 1556.707903 $77835.2500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 107 111 85.134918 $4256.7400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 108 111 115.806347 $2895.1500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 9 9 72.500000 $1812.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 169 214 1663.142868 $41578.5300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 378 417 2457.057527 $122852.8800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4671 5066 31398.505346 $1569924.8900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 463 480 2080.846051 $104042.3300 $50.0000
INTR -T1013 INTERPRETER 174 205 468.832386 $23441.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2449 3052 16039.794849 $160397.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 778 907 5091.001600 $363701.0700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 16 17 83.142857 $5939.7300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 153 166 1001.944445 $57311.2500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 6 6 36.071428 $2063.2800 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 21 21 90.631748 $6474.7400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 48 50 209.826987 $14990.0500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 667 809 4264.047638 $304623.3700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 9 10 21.133333 $1509.7700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 86 94 420.692861 $24046.7900 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 6 6 20.642856 $1179.9500 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 28 28 102.323812 $7310.0200 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 37 37 113.038099 $8075.4600 $71.4400
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 9.714286 $555.2700 $57.1600
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.509589 $116.1900 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 3 3 3.000000 $684.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 7 7 6.411111 $2923.4600 $456.0000
SENS -V5264 EARMOLD 22 22 21.176257 $381.1800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1013 1191 6535.485344 $466895.0600 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 18 21 78.871427 $5634.5600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 6 15.642857 $894.7700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 28 28 162.534921 $11611.4900 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 49 53 237.283339 $16951.5400 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 43 47 228.464288 $3171.0800 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.000000 $69.4000 $13.8800
TRAV -TRAVS Travel by mile 884 1260 74845.114478 $33306.0800 $0.4500
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Subtotal (Total Children Is Unduplicated) 7150 20662 155386.264044 $4201051.6400 $27.0400
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Total 25145 165388.180591 $4686705.3100 $28.3400
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Number of Children (Unduplicated) With at Least One Authorization 8409