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: 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 22866 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 238 239 1404.985709 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 43 43 10302.588888 $383256.3000 $37.2000
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Subtotal (Total Children Is Unduplicated) 281 282 11707.574597 $383256.3000 $32.7400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 80 102 89.676247 $4349.3200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 38 38 43.446826 $2437.3700 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 20 20 29.912699 $583.6000 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 7 16.912699 $400.3200 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 15.912699 $233.6000 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 42 42 42.212699 $931.6300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 16.184921 $116.5300 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 2.466667 $25.7800 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 15.823810 $457.6200 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 14.912699 $672.2600 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 30 30 71.168254 $982.8300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 15 15 37.299218 $784.7700 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 271 303 308.532289 $23180.0300 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 18 20 15.761112 $714.3000 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 9 18.581920 $2151.9800 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 21 26 34.250381 $1712.5200 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 5 10.000000 $500.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 38 38 54.787661 $2739.3800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 9 12 22.128767 $1659.6600 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 22 22 42.005479 $3150.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 10 10 19.000000 $1425.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 5 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 20 20 34.205479 $1898.4100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 6 10.000000 $555.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 253 259 497.829546 $37337.2300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 135 136 252.088737 $18906.6500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 63 63 121.500000 $9112.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 30 30 56.005479 $4200.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 86 87 168.785714 $12658.9300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 78 78 129.043833 $9678.2900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 357 363 700.110499 $38856.1400 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 183 185 333.109783 $18487.5900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 260 336 663.000000 $49725.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 94 116 229.071429 $17180.3600 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 0.822222 $42.6300 $51.8500
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 17 17 20.955554 $2980.4900 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 6.247619 $312.3800 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 7 7 39.942857 $1997.1500 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 73 75 30.550000 $1570.5800 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 107 127 113.097640 $5814.3400 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 16 16 3.438888 $176.7900 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 30 31 13.325952 $685.0900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 1.167123 $60.0000 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 4 4 2.011111 $103.3900 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 98 99 66.543935 $3421.0300 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 2.094444 $107.6700 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 10 11 5.005556 $257.3400 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.8200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 49 49 33.060318 $1699.6300 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 4 1.227778 $63.1200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 55 60 41.412481 $2129.0100 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.202740 $10.4200 $51.4000
PSTH -97161TL PT EVAL LOW COMPLEXITY 8 8 1.661110 $85.3900 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 17 18 8.564688 $440.3100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 3 3 1.249315 $64.2300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 50 56 26.227549 $1348.3600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 5 5 1.872602 $96.2700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 5 6 1.221993 $62.8200 $51.4100
SCREEN-T1023 SCREENING 36 36 36.300000 $1815.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 4.505024 $68.0700 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 158 179 143.600285 $7382.5000 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 13 14 13.846826 $711.8700 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 13 14 9.577778 $492.3900 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 3 3 2.211111 $113.6700 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.483333 $24.8500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 196 217 84.916426 $4365.5400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 5.266667 $270.7600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 2.333333 $119.9600 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 2.288890 $102.6800 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.455556 $20.4400 $44.8600
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 5 5 55.714286 $2948.9500 $52.9300
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Subtotal (Total Children Is Unduplicated) 2094 3534 4962.130536 $314359.3900 $63.3500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 67 75 130.833626 $654166.5000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.211111 $14.6400 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.000000 $138.7000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 17 17 22.353837 $5177.5900 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 878 1077 961.178517 $48059.0200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 72 80 64.449347 $3222.4500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 189 214 193.873826 $4846.8500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1109 1228 1941.702392 $97085.1800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 53 54 85.879367 $4293.9800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 72 75 91.151512 $2278.7900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 877 962 1234.182939 $61709.1500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 27 29 34.577777 $1728.8900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 77 91.663089 $2291.5600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 403 448 551.843664 $27592.2500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 22 23 25.655555 $1282.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 26 44 53.149997 $1328.7400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1195 1248 1445.907929 $72295.3600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 56 57 92.830158 $4641.5100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 67 67 87.512701 $2187.8200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 17 18 309.285713 $7732.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 107 120 1097.204769 $27430.1100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 703 796 6176.599992 $308830.0100 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.928571 $46.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3824 4151 27371.346126 $1368566.6500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 460 477 3107.085719 $155354.1900 $50.0000
INTR -T1013 INTERPRETER 176 214 634.398336 $31719.9200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2465 3301 18342.201581 $183421.9200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 595 668 4378.744442 $315094.4300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 16 17 105.463095 $7589.1200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 73 79 645.495233 $37180.5400 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.857143 $567.7700 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 90 94 552.986119 $39792.8600 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 6.000000 $431.7600 $71.9600
OCCT -97530TLHM OT SESSION BY OT ASST 2 2 19.285714 $1110.8600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 536 605 3553.436710 $255705.1900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 11 11 62.947620 $4529.7000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 41 43 391.254763 $22520.6100 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 22.250000 $1280.7100 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 71 79 400.022228 $28785.5500 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 27.539286 $1981.7200 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 2.285714 $131.5600 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 10.000000 $575.6000 $57.5600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 4 4 3.150837 $361.7400 $114.8100
SENS -V5060 BEHIND EAR HEARING AID 5 5 6.633333 $1523.0700 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 5 6 4.361112 $2002.7500 $459.2300
SENS -V5264 EARMOLD 19 20 21.569177 $391.0500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 853 967 6293.033464 $452846.5700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 25 26 146.034126 $10508.6100 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.857143 $164.5700 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 10.714286 $617.1400 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 93 98 550.842862 $39638.6000 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 4 4 31.952382 $2299.2900 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 6 6 34.176191 $477.1000 $13.9600
TRAV -TRAVS Travel by mile 984 1446 88050.179620 $39182.3300 $0.4500
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Subtotal (Total Children Is Unduplicated) 6572 19050 169493.080751 $4344733.9100 $25.6300
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Total 22866 186162.785884 $5042349.6000 $27.0900
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Number of Children (Unduplicated) With at Least One Authorization 7169