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: 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 24856 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 1 1 0.250000 $9.2500 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 268 273 337.769827 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 64 64 12765.736506 $472332.2400 $37.0000
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Subtotal (Total Children Is Unduplicated) 333 338 13103.756333 $472341.4900 $36.0500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 130 147 120.462947 $5842.4600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 19 19 67.400793 $3754.9000 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 313 362 431.330158 $10136.2600 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 17 17 17.000000 $399.5000 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 19 19 15.993075 $233.1800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 85 85 58.554764 $1376.0400 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 16 12.733334 $124.6600 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 10 10 10.000000 $97.9000 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 17 17 14.033333 $403.0400 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 10 10 10.000000 $447.6000 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 26 26 22.922222 $314.2600 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 17 17 21.714286 $453.6100 $20.8900
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $60.5700 $60.5700
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 15 11.499999 $517.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 2.536986 $291.7600 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 21 26 33.459361 $1672.9700 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 5 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 68 69 103.607459 $5180.3700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 23 30 61.928571 $4644.6500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 14 14 23.011111 $1725.8300 $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 5 5 10.000000 $750.0000 $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 5 5 8.011111 $600.8300 $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 40.278311 $2235.4500 $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 305 310 562.715519 $42203.6900 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 298 300 567.042347 $42528.1700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 100 101 195.066667 $14630.0000 $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 90 90 161.939530 $12145.4600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 465 467 879.143373 $48792.4700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 253 253 474.277626 $26322.4100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 200 216 422.000000 $31650.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 81 90 195.788454 $14684.1400 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 6 6 23.452381 $1172.6200 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 9 10 35.300001 $1765.0100 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 75 77 43.293645 $2210.1100 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.144444 $7.3700 $51.0300
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 0.283333 $14.4600 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 125 149 141.584135 $7227.9100 $51.0500
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 29 31 18.369863 $937.7800 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.100000 $5.1100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 112 117 67.087376 $3424.8000 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 5 5 1.694444 $86.5000 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 1.504186 $76.7900 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 2.285714 $116.6900 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 50 52 37.487299 $1913.7100 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.433333 $22.1200 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 63 75 54.185137 $2766.1400 $51.0500
PSTH -97161TL PT EVAL LOW COMPLEXITY 2 2 1.388889 $70.9000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 28 29 19.288889 $984.7000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 73 78 38.000076 $1939.9100 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 3 2.094444 $106.9200 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 2 1.977778 $100.9700 $51.0500
SCREEN-T1023 SCREENING 36 36 34.505556 $1725.2800 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 1.167123 $17.5100 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 118 153 164.825700 $8414.3500 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.133333 $6.8100 $51.0400
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.394444 $20.1300 $51.0400
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 14 14 13.085008 $667.9900 $51.0500
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 4 4.000000 $204.2000 $51.0500
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.483333 $24.6700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 209 224 104.515268 $5335.4800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 3.344444 $170.7300 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.133333 $108.9100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.487748 $75.9500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 2 2 2.000000 $102.1000 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 22 23 14.155859 $630.6400 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 47.571428 $2500.8300 $52.5700
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Subtotal (Total Children Is Unduplicated) 2323 4091 5821.619087 $346851.4400 $59.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 84 87 96.642455 $483212.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 30 30 79.718219 $3985.9100 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 51.428571 $3541.3700 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 6 6 17.428572 $1200.1300 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 20 20 26.584517 $6114.3900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 864 1043 857.591998 $42879.8100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 76 87 52.113151 $2605.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 221 258 180.486914 $4512.2100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1205 1329 2157.286506 $107864.3400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 59 61 96.297618 $4814.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 88 95 112.105552 $2802.6300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 967 1081 1394.464294 $69723.2400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 28 29 39.855555 $1992.7800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 55 91 116.340475 $2908.5100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 407 463 604.460004 $30223.0400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 24 24 38.939684 $1946.9900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 18 33 39.161108 $979.0200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1287 1336 1717.875399 $85893.8000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 53 56 90.417460 $4520.8800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 90 93 119.137301 $2978.4300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 14 16 121.357141 $3033.9300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 126 163 784.285699 $19607.2000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 649 784 6077.325355 $303866.2200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4342 4732 29687.540564 $1484377.7800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 352 367 2361.010295 $118050.6100 $50.0000
INTR -T1013 INTERPRETER 171 209 513.118100 $25655.9100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2670 3484 18706.495297 $187065.0700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 669 780 4443.815059 $317466.3600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 18 19 123.483335 $8821.6500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 128 138 868.232134 $49662.9200 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 10.857143 $621.0300 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 34 35 164.769839 $11771.1800 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 22.285714 $1592.0900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 588 674 3807.534119 $272010.4600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 9 9 25.803174 $1843.3800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 67 76 414.159520 $23673.4000 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 16.321429 $932.9300 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 42 42 226.923808 $16211.4500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 4 4 28.214285 $2015.6200 $71.4400
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 16.571429 $947.2200 $57.1600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 10.000000 $571.6000 $57.1600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.194520 $22.1700 $113.9900
SENS -V5060 BEHIND EAR HEARING AID 3 3 3.000000 $684.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 2.800000 $1276.8000 $456.0000
SENS -V5264 EARMOLD 12 12 11.216896 $201.9100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 955 1106 6620.630907 $472978.1100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 26 30 147.000000 $10501.6800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 3.771429 $215.7200 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 49 50 339.614285 $24262.1000 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 12 13 54.138096 $3867.6300 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 17 19 107.723809 $1495.2100 $13.8800
TRAV -TRAVS Travel by mile 972 1422 119062.734838 $52982.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 7058 20427 202671.263572 $4282986.2500 $21.1300
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Total 24856 221596.638992 $5102179.1900 $23.0200
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Number of Children (Unduplicated) With at Least One Authorization 7736