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 12190 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 232 233 1396.909519 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 1331.766667 $49541.7200 $37.2000
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Subtotal (Total Children Is Unduplicated) 239 240 2728.676186 $49541.7200 $18.1600
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 77 98 82.961961 $4023.6700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 3.383333 $189.8000 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.055556 $1.0800 $19.5300
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.055556 $1.3200 $23.6900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.055556 $0.8200 $14.6900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 0.055556 $1.2300 $22.0900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 0.505556 $3.6400 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 0.505556 $14.6200 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.055556 $2.5100 $45.1100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.505556 $6.9800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.055556 $22.2100 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 27 30 30.000000 $2253.9000 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 2 0.361112 $16.3700 $45.3300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.361112 $41.8300 $115.8400
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 36 36 53.143217 $2657.1600 $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 3 3 6.000000 $450.0000 $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 4 4 8.000000 $600.0000 $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 18 19 37.000000 $2775.0000 $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 1 1 2.533333 $126.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.572223 $29.4200 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 19 21 19.688889 $1012.2100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 4.972222 $255.6200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 2 0.361111 $18.5600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 3 2.483333 $127.6700 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 3.327778 $171.0800 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.188889 $9.7100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 21 22 21.887303 $1125.2400 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 7 2.355555 $121.1000 $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 1 1.000000 $44.8600 $44.8600
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Subtotal (Total Children Is Unduplicated) 284 392 471.253184 $28038.8700 $59.5000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 15 17 21.424168 $107120.0000 $4999.9600
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 826 1010 897.334961 $44866.8400 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 71 79 62.449347 $3122.4500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 141 149 116.444458 $2911.1100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1099 1214 1935.902392 $96795.1800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 53 54 85.879367 $4293.9800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 71 73 89.882105 $2247.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 869 953 1228.838495 $61441.9300 $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 395 438 544.754776 $27237.8100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 22 23 25.655555 $1282.7800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 42 50.416663 $1260.4100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1182 1230 1433.090469 $71654.4800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 56 57 92.830158 $4641.5100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 64 64 85.701589 $2142.5400 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 6.285714 $157.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 8.571429 $214.2900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 642 732 5859.398803 $292969.9400 $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 118 126 883.723816 $44186.1900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 7 7 39.571430 $1978.5700 $50.0000
INTR -T1013 INTERPRETER 164 200 607.326907 $30366.3500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2465 3301 18342.201581 $183421.9200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 60 67 516.635712 $37177.1300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 5 39.571428 $2279.3200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 50 56 351.803969 $25315.7900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 3.714286 $267.2800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 19.000000 $1093.6400 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.285714 $596.2400 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 2 0.361112 $165.8700 $459.3300
SENS -V5264 EARMOLD 1 2 0.361112 $6.5500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 94 652.015877 $46919.0300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 5.857143 $421.4800 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 0.285714 $16.4600 $57.6000
TRAV -TRAVS Travel by mile 984 1446 88050.179620 $39182.3300 $0.4500
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Subtotal (Total Children Is Unduplicated) 4879 11558 122193.925307 $1142052.0300 $9.3500
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Total 12190 125393.854677 $1219632.6200 $9.7300
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Number of Children (Unduplicated) With at Least One Authorization 5166