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 12426 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 309 320 1839.314283 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 6 215.522222 $8017.4300 $37.2000
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Subtotal (Total Children Is Unduplicated) 314 326 2054.836505 $8017.4300 $3.9000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 92 110 89.670062 $4349.0100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.082192 $60.7100 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 6 6.000000 $117.0600 $19.5100
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.044444 $0.3200 $7.1900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.044444 $1.2800 $28.8900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 1.844444 $25.4700 $13.8100
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 28 30 30.000000 $2253.9000 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.800000 $81.5800 $45.3200
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 60 62 79.930083 $3996.5100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 0.500000 $37.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $444.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 25 25 50.000000 $3750.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 18 18 36.000000 $2700.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 10 10 20.000000 $1500.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 24 24 47.000000 $2608.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 6 7 13.000000 $975.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 2 0.666667 $94.8200 $142.2400
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 2.400000 $120.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 2.344445 $120.5300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 16 20 18.861111 $969.6500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 4.611111 $237.0600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.066667 $3.4300 $51.4300
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.044445 $2.2900 $51.4700
PSTH -97161 PT EVAL LOW COMPLEXITY 4 5 4.411111 $226.7700 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.8500 $51.4000
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 5 2.644444 $135.9500 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.172223 $8.8600 $51.4300
SPCH -92521 EVAL OF SPEECH FLUENCY 16 19 15.774603 $810.9700 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.066667 $3.4300 $51.4300
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.311110 $67.4000 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 319 432 532.568278 $31815.7800 $59.7400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 12 13.721918 $68609.5000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 3 3 2.814155 $140.7100 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.800000 $648.5400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 865 1068 908.457091 $45423.0300 $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 176 186 134.127301 $3353.1900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1155 1298 1937.453598 $96872.7100 $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 924 1025 1096.795681 $54839.7700 $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 450 512 681.534020 $34076.7600 $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 1248 1330 1456.427751 $72821.4400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 54 55 70.740475 $3537.0200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 70 73 86.544448 $2163.6200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 28.428572 $710.7100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 12.714286 $317.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 80 83 444.268252 $22213.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 141 153 839.668250 $41983.4400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 11 11 77.214284 $3860.7200 $50.0000
INTR -T1013 INTERPRETER 198 255 591.721428 $29586.0800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2527 3387 17163.793619 $171637.9800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 83 91 504.908732 $36333.2200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 4.428571 $318.6800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 8 10 61.000001 $3513.5900 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 1.714286 $123.3600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 81 90 450.617462 $32426.4300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.000000 $287.8400 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 6 37.714285 $2170.8400 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 2 2 7.142857 $514.0000 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 0.142857 $10.2800 $71.9800
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.800000 $826.6000 $459.2200
SENS -V5264 EARMOLD 2 3 2.466667 $44.7200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 103 115 676.272224 $48664.5300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 16.285714 $1171.9200 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.571429 $148.1100 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.714286 $123.3600 $71.9600
TRAV -TRAVS Travel by mile 1039 1504 82900.732266 $36890.8300 $0.4500
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Subtotal (Total Children Is Unduplicated) 4820 11668 110628.170359 $832348.1900 $7.5200
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Total 12426 113215.575142 $872181.4000 $7.7000
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Number of Children (Unduplicated) With at Least One Authorization 5211