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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 25222 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 318 329 1996.205551 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 46 48 9558.133333 $355562.5600 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 363 377 11554.338884 $355562.5600 $30.7700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 96 115 93.287109 $4524.4300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 29 29 26.515448 $1487.5100 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 2.000000 $31.6800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 89 93 93.911111 $1832.2100 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 10 10 10.000000 $236.7000 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 10 8.469634 $124.3300 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 51 51 36.173809 $798.3500 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 11 11 8.983333 $64.6800 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 3.000000 $31.3500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 19 19 16.983333 $491.1600 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 6 6 6.000000 $270.4800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 39 39 37.150000 $513.0400 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 7.761034 $163.2900 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.261111 $22.7000 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 297 326 360.151077 $27058.1400 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 19 19 19.016439 $861.8200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.973517 $228.5500 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 14 16 27.536986 $1376.8500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 2 0.568797 $28.4400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 67 70 84.715797 $4235.8000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 13 18 32.000000 $2400.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 18 18 34.005479 $2550.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 12 12 20.500000 $1537.5000 $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 7 7 12.011111 $900.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 13 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 5 5 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 14 18 33.505479 $2512.9100 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 32 32 59.500000 $3302.2500 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 12 12 18.159056 $1007.8200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 374 376 743.572146 $55767.9200 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 132 133 259.510958 $19463.3300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 97 99 195.500000 $14662.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 67 68 134.000000 $10050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 130 131 254.000000 $19050.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 66 67 131.000000 $9825.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 524 537 1057.715003 $58703.1900 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 197 204 389.077625 $21593.8100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 258 315 614.220482 $46066.5500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 97 116 228.500000 $17137.5000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 10 11 8.166668 $1161.5600 $142.2300
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 10 50.280952 $2514.0500 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 63 65 26.169841 $1345.3900 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 2 2 1.316667 $67.6900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 162 185 170.445506 $8762.5800 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 4 4 1.011111 $51.9800 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 32 34 22.400838 $1151.6300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 4 4 2.543303 $130.7500 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 3 3 2.061111 $105.9600 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 1.082192 $55.6400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 105 105 82.184746 $4225.1200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 3.338889 $171.6500 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 23 27 10.422221 $535.8000 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 42 45 18.599999 $956.2200 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.372222 $19.1300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 61 68 47.310652 $2432.2300 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 4 4 1.911111 $98.2500 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 17 19 9.176178 $471.7400 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 5 5 2.375343 $122.1200 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 70 74 32.542922 $1673.0400 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 3 1.200533 $61.7200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 13 14 2.455557 $126.2500 $51.4100
SCREEN-T1023 SCREENING 31 31 32.733333 $1636.6700 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.805479 $12.1700 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 210 236 187.179857 $9622.9300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.188889 $9.7100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 19 20 4.788887 $246.1900 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.316667 $16.2800 $51.4200
SPCH -92522 EVAL OF SPCH SOUND PROD 15 15 13.850000 $712.0300 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.472222 $24.2800 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 219 237 109.722570 $5640.8400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 5 4.372222 $224.7700 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 2.544444 $130.8100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.394444 $123.1000 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 9 9 3.472223 $155.7700 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.272222 $12.2100 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 9 11 94.571429 $5005.6600 $52.9300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2640 4295 6071.289324 $384734.0000 $63.3700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 71 73 97.570351 $487851.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 5 5 3.803044 $190.1500 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 3.194444 $221.5300 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 16 16 42.791389 $9911.3400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 929 1153 988.282893 $49414.3100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 53 65 52.800263 $2640.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 257 294 255.278588 $6381.9700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1173 1316 1949.570265 $97478.5500 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 59 61 77.326189 $3866.3100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 71 76 91.638098 $2290.9600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 938 1040 1109.142506 $55457.1100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 40 43 57.494445 $2874.7300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 34 59 47.349993 $1183.7300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 460 522 692.550687 $34627.6000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 41 48 46.281747 $2314.1000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 18 29 32.542858 $813.5800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1266 1348 1472.427751 $73621.4400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 54 55 70.740475 $3537.0200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 71 74 86.561115 $2164.0400 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 21 21 340.714290 $8517.8500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 139 161 1104.109527 $27602.7600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 121 129 671.595633 $33579.7800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4599 5032 31185.150600 $1559257.8200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 536 581 3544.498417 $177225.0200 $50.0000
INTR -T1013 INTERPRETER 215 280 631.828571 $31591.4400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2527 3387 17163.793619 $171637.9800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 679 809 4488.100798 $322963.6700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 19 20 140.428572 $10105.2300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 78 84 624.801589 $35988.5700 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 5.571428 $320.9100 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 76 87 385.925786 $27771.2700 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 9.438096 $679.1700 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 3.200000 $184.3200 $57.6000
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 34.285714 $1974.8600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 569 669 3674.019650 $264382.4400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 16 16 87.671429 $6308.8500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 44 50 296.776191 $17082.4400 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 12.250000 $705.1000 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 57 66 305.740479 $22001.0900 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 8 8 38.019048 $2735.8600 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.134247 $15.4100 $114.7700
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.345205 $79.2600 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 5.800000 $2663.4800 $459.2200
SENS -V5264 EARMOLD 16 17 17.873821 $324.0500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 990 1182 6812.605556 $490235.0900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 37 41 234.009520 $16839.3500 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 10.571428 $608.9100 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 4.000000 $230.4000 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 84 99 447.599997 $32209.3300 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 8.357143 $601.3800 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 6.071429 $84.7600 $13.9600
TRAV -TRAVS Travel by mile 1039 1504 82900.732266 $36890.8300 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7091 20550 162376.367150 $4140767.1600 $25.5000
-------------------------------------------------------------------------------------------------------------------------------------
Total 25222 180001.995358 $4881063.7300 $27.1200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 8389