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 13089 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 262 263 791.165082 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 6.742857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 202.333333 $7526.8000 $37.2000
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Subtotal (Total Children Is Unduplicated) 269 270 1000.241272 $7526.8000 $7.5200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 110 129 110.899659 $5378.6100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 3.164384 $177.5200 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 7.569047 $119.8900 $15.8400
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $14.6800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.288889 $6.3800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.2000 $7.2000
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 3.000000 $63.1200 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.283333 $24.6300 $86.9300
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 6 7 7.000000 $525.9100 $75.1300
EVAL -96111 DEVELOPMENTAL EVALUATION 14 16 24.005556 $1200.2800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 3 3 4.322222 $216.1100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 53 55 79.969765 $3998.5000 $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 3 3 6.000000 $450.0000 $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 9 9 18.000000 $1350.0000 $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 1 0.411111 $58.4700 $142.2300
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 13.457142 $672.8600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.961111 $49.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 12 14 13.127778 $674.9000 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.394444 $20.2800 $51.4000
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 10.285714 $528.7900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 4 2.066667 $106.2500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.844444 $43.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 3 3 2.161111 $111.1000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.105556 $5.4300 $51.4300
SPCH -92521 EVAL OF SPEECH FLUENCY 13 16 13.522222 $695.1800 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 9 1.638888 $84.2500 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.033333 $1.7600 $52.8800
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Subtotal (Total Children Is Unduplicated) 307 408 539.340154 $31233.7500 $57.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 23 23.543836 $117719.0000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 901 1081 944.380908 $47219.2400 $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 177 185 159.481267 $3987.0400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1270 1397 2027.986654 $101399.3500 $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 1053 1179 1272.081063 $63604.1000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 63 63 63.625396 $3181.2700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 36 62 76.922222 $1923.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 452 506 638.304758 $31915.2100 $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 1325 1399 1444.337673 $72216.9400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 58 65 74.319840 $3715.9800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 90 92 138.802380 $3470.0600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 22.857143 $571.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 1 2 11.714286 $292.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 94 99 670.666664 $33533.3600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 153 167 1152.823810 $57641.2300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 14 105.142857 $5257.1400 $50.0000
INTR -T1013 INTERPRETER 194 260 614.101585 $30705.0800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2705 3675 18813.606189 $188136.1700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 40 191.149205 $13755.1200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 6.642858 $478.0200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 13 13 123.999999 $7142.4000 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 29 32 149.092855 $10728.7300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 12.857142 $925.2000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 3 4 25.571428 $1471.9000 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.428571 $390.6400 $71.9600
SENS -V5264 EARMOLD 1 1 0.411111 $7.4500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 59 68 326.434921 $23490.2600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.000000 $791.5600 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.266667 $91.1500 $71.9600
TRAV -TRAVS Travel by mile 1088 1660 98164.631043 $43683.2600 $0.4500
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Subtotal (Total Children Is Unduplicated) 4940 12411 127605.416335 $882503.8600 $6.9200
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Total 13089 129144.997761 $921264.4000 $7.1300
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Number of Children (Unduplicated) With at Least One Authorization 5243