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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 13048 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 273 279 1496.805547 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 4.977777 $185.1700 $37.2000
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Subtotal (Total Children Is Unduplicated) 280 286 1501.783324 $185.1700 $0.1200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 133 154 103.937333 $5040.9500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 0.366667 $20.5700 $56.1100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 30 32 31.144444 $607.6300 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.188889 $4.1700 $22.0700
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 11 11 11.000000 $826.4300 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.305556 $13.8500 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.305556 $35.3900 $115.8300
EVAL -96111 DEVELOPMENTAL EVALUATION 22 28 33.549925 $1677.5000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 6 7 10.219178 $510.9600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 44 44 67.876550 $3393.8300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
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 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 17 17 32.285714 $2421.4300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 15 28.285714 $2121.4300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 19 19 38.000000 $2109.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 17 18 35.000000 $2625.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 6 7 14.000000 $1050.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 7.533333 $376.6700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 3 3 8.638095 $431.9000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.738889 $37.9900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 19 20 18.838889 $968.5100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.316667 $67.6900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 8 9 3.888889 $199.9300 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.138889 $7.1400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.394445 $20.2800 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 2.433333 $125.1000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.188889 $9.7100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 25 28 31.811112 $1635.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.616666 $83.1100 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 2.000000 $89.7200 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.571429 $189.0300 $52.9300
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Subtotal (Total Children Is Unduplicated) 363 465 532.575051 $29545.6200 $55.4800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 8.402588 $42013.0000 $5000.0100
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 10 7.766666 $388.3300 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 802 986 805.734962 $40286.8600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 74 82 50.930300 $2546.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 141 149 109.059678 $2726.4900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1187 1345 2010.863868 $100543.1000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 63 66 104.077777 $5203.8900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 81 87 98.449564 $2461.2400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 929 1037 1249.307144 $62465.3500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 21 22 26.666666 $1333.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 51 88 85.549207 $2138.7300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 433 486 610.993387 $30549.6000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 25 26 27.283334 $1364.1700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 16 29 24.622222 $615.5600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1265 1328 1625.180144 $81258.9200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 54 55 68.988890 $3449.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 79 83 96.005555 $2400.1400 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 18.571428 $464.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 615 701 5171.504782 $258575.2600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 122 135 761.317465 $38065.8400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 11 12 60.571429 $3028.5700 $50.0000
INTR -T1013 INTERPRETER 166 201 500.898339 $25044.9200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2637 3525 16923.353973 $169233.4700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 79 85 571.136512 $41098.9500 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 6 6 50.857144 $2929.3700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 87 94 442.076193 $31811.7500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 1 1 3.428571 $197.3500 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 4.714286 $339.2400 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.305556 $140.3400 $459.2900
SENS -V5264 EARMOLD 1 1 0.305556 $5.5400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 127 137 883.864289 $63602.8500 $71.9600
TRAV -TRAVS Travel by mile 1033 1506 81995.867851 $36488.1600 $0.4500
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Subtotal (Total Children Is Unduplicated) 5236 12297 114400.655326 $1053233.7800 $9.2100
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Total 13048 116435.013701 $1082964.5700 $9.3000
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Number of Children (Unduplicated) With at Least One Authorization 5607