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: 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 25699 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 269 270 971.098414 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 6.742857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 72 72 6794.094444 $252740.3100 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 343 344 7771.935715 $252740.3100 $32.5200
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $206.7200 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 116 135 115.244864 $5589.3500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 28 28 26.875114 $1507.6900 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 18 18 29.419047 $466.0000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 8 8 8.005556 $156.1900 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 8 7.005556 $165.8200 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 9 9 7.046652 $103.4500 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 61 61 51.223809 $1130.5100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 15.461112 $111.3200 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 0.033333 $0.3500 $10.4400
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 16.538889 $478.3100 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 4 4.000000 $180.3200 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 40 40 25.238889 $348.5500 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 16 16 23.961112 $504.1400 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.366667 $22.3700 $61.0100
AUDE -92651 AEP HEARING STATUS DETER I&R 4 4 3.941270 $342.6600 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 283 292 289.577778 $21755.9800 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 18 18 13.858829 $628.0900 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 11.767460 $1362.7900 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 15 17 26.005556 $1300.2800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 3 3 4.322222 $216.1100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 60 63 84.755479 $4237.7900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 15 19 32.106849 $2408.0100 $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 13 13 22.500000 $1687.5000 $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 12 12 24.000000 $1800.0000 $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 373 374 741.072146 $55580.4200 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 133 134 259.675342 $19475.6600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 96 98 193.500000 $14512.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 69 70 138.000000 $10350.0000 $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 1057.215003 $58675.4400 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 195 202 383.242009 $21269.9400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 257 314 612.220482 $45916.5500 $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 13 13 8.022220 $1140.9700 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 8.104762 $405.2400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 9 9 32.719047 $1635.9600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 73 74 30.799208 $1583.3900 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.683333 $35.1300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 158 176 165.638445 $8515.4900 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 1.366667 $70.2600 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 4 4 1.233333 $63.4000 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 33 33 21.579376 $1109.4000 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 4 4 23.021527 $1183.5400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.061111 $3.1400 $51.4000
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 10.450098 $537.2400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 89 89 64.260784 $3303.6500 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 2.805556 $144.2400 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 29 29 10.011108 $514.6600 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 2.450000 $125.9500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 46 51 22.761109 $1170.1400 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.033333 $1.7100 $51.3600
PSTH -97161 PT EVAL LOW COMPLEXITY 62 71 52.788893 $2713.9000 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 2 2 0.433333 $22.2800 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 12 14 8.774659 $451.1100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 4 4 1.364384 $70.1400 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.405556 $20.8500 $51.4200
PSTH -97163 PT EVAL HIGH COMPLEXITY 58 61 36.616667 $1882.4600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 0.861111 $44.2700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 17 18 11.779366 $605.5800 $51.4100
SCREEN-T1023 SCREENING 37 37 37.000000 $1850.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 200 223 176.465090 $9072.0600 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 5 5 2.888889 $148.5200 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 17 17 10.576188 $543.7100 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 2 2 0.583333 $29.9900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 8 5.393988 $277.3100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 5 5 1.625495 $83.5700 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.500000 $77.1200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 170 187 89.788088 $4616.0300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 8 10 8.210959 $422.1200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 3.411111 $175.3600 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.105556 $5.4300 $51.4300
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 4.600000 $206.3600 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.344444 $15.4500 $44.8500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 10 12 72.695239 $3847.7500 $52.9300
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.571429 $189.0300 $52.9300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2462 4128 5963.646945 $379542.8000 $63.6400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 83 89 114.981484 $574905.5000 $4999.9800
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 1.533333 $106.3300 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 14 14 12.405557 $2873.4100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 971 1172 1029.598774 $51480.1300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 56 66 40.305024 $2015.2300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 257 295 278.224618 $6955.6200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1289 1417 2043.153321 $102157.6800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 71 76 107.787301 $5389.3600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 98 103 124.285716 $3107.1500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1062 1189 1280.431063 $64021.6000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 64 64 63.969840 $3198.4900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 37 63 77.361111 $1934.0300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 461 515 644.632535 $32231.6000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 35 44 33.799995 $1689.9800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 16 23 25.053968 $626.3500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1342 1417 1455.748784 $72787.4900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 58 65 74.319840 $3715.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 93 95 140.096825 $3502.4200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 12 12 296.819048 $7420.4700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 107 119 872.533335 $21813.3400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 132 138 918.621426 $45931.0900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4539 5036 30354.054995 $1517703.7500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 718 748 5089.743614 $254487.4000 $50.0000
INTR -T1013 INTERPRETER 211 285 644.637299 $32231.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2707 3679 18836.177617 $188361.8900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 659 725 4220.741260 $303724.7000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 18 21 149.492859 $10757.4900 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 82 86 696.171423 $40099.5000 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 27.285714 $1571.6600 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 91 95 538.623809 $38759.3800 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.094444 $6.7900 $71.9300
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 2.400000 $138.2400 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 538 586 3193.442038 $229800.2400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 14 15 55.069046 $3962.7700 $71.9600
PHY -97110HM PT SESSION BY PT ASST 36 43 265.278572 $15269.4400 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 5.000000 $287.8000 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 63 68 371.008732 $26697.7700 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 7 7 58.400000 $4202.4700 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.126104 $14.4800 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.005556 $1.2900 $231.4300
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.733333 $1714.4100 $459.2200
SENS -V5264 EARMOLD 13 13 10.945434 $198.4400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 900 1020 6174.020594 $444282.8000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 30 33 183.945238 $13236.7000 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 9 55.571426 $3200.9200 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 91 95 450.473819 $32416.1100 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 5 5 8.168254 $587.7800 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 3.714286 $51.8500 $13.9600
TRAV -TRAVS Travel by mile 1091 1665 98197.631042 $43697.9400 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7125 21227 179231.619406 $4215329.1000 $23.5200
-------------------------------------------------------------------------------------------------------------------------------------
Total 25699 192967.202066 $4847612.2000 $25.1200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 7850