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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 12964 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 277 284 812.273006 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 42.142857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 7 7 353.222222 $13139.8700 $37.2000
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Subtotal (Total Children Is Unduplicated) 286 293 1207.638085 $13139.8700 $10.8800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 94 110 81.205164 $3938.4700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 5.288889 $296.7100 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 6.880953 $109.0000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.094444 $1.8400 $19.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.094444 $2.2300 $23.6600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.094444 $1.3900 $14.6700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 0.150000 $3.3100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 0.094444 $0.8300 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 0.094444 $2.7300 $28.9100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.094444 $4.2600 $45.0600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 0.094444 $1.3000 $13.8000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.094444 $23.0300 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.166667 $14.4900 $86.9600
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 12 14 14.000000 $1051.8200 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.094444 $4.2800 $45.3000
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.094444 $10.9300 $115.7600
EVAL -96111 DEVELOPMENTAL EVALUATION 28 39 62.892085 $3144.6100 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 4 7.000000 $350.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 99 104 94.583106 $4729.1700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 3.000000 $225.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 3.000000 $225.0000 $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 14 14 26.005479 $1950.4100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1350.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 12 12 22.005479 $1221.3100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 8 9 18.000000 $999.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 16.000000 $1200.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $300.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 2.100000 $105.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 11.857143 $592.8600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 6 8 0.894445 $45.9900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 15 15 13.216666 $679.4700 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 9 9 1.700000 $87.4000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.588889 $30.2800 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 1.183333 $60.8300 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 1.033333 $53.1200 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.372222 $19.1300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 5.407937 $278.0300 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.205556 $10.5700 $51.4200
SPCH -92521 EVAL OF SPEECH FLUENCY 24 26 21.922222 $1127.0200 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 0.372222 $19.1300 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.172222 $8.8500 $51.4000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 8 2.144444 $110.2400 $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 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.866667 $95.9700 $51.4100
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Subtotal (Total Children Is Unduplicated) 354 466 510.159563 $28989.2100 $56.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 23 20.692161 $103460.0000 $4999.9600
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 868 1045 913.103349 $45655.2500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 80 88 55.698276 $2784.9300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 155 165 132.258892 $3306.4700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1216 1352 1944.660321 $97233.0300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 55 57 76.912699 $3845.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 78 82 78.694443 $1967.3600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 991 1109 1237.792861 $61889.6900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 41 45 61.430160 $3071.5200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 42 70 60.338890 $1508.4800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 454 515 606.051981 $30302.5900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 19 20 19.459523 $972.9800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 43 39.111108 $977.7700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1272 1339 1415.876988 $70793.8800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 52 54 48.296033 $2414.8000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 79 83 90.798411 $2269.9600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 24.000000 $600.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 3 3 9.142857 $228.5700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 82 84 498.092064 $24904.6000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 191 203 1401.515868 $70075.8000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 18 20 119.428571 $5971.4300 $50.0000
INTR -T1013 INTERPRETER 183 235 494.340672 $24717.0300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2713 3706 18227.438829 $218729.2100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 56 61 290.265876 $20887.4700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.285714 $164.4800 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 8 9 34.642858 $1995.4300 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 24.000000 $1382.4000 $57.6000
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 16.571428 $1192.4900 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 60 66 266.252383 $19159.4800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 11.428572 $822.3900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 3 3 16.000001 $920.9600 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 4.714286 $339.2400 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.094444 $43.3500 $459.0100
SENS -V5264 EARMOLD 1 1 0.094444 $1.7100 $18.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 88 93 509.634920 $36673.3100 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 13.580952 $977.2900 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 2.714286 $195.3200 $71.9600
TRAV -TRAVS Travel by mile 1108 1615 80944.394617 $36020.2500 $0.4500
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Subtotal (Total Children Is Unduplicated) 5000 12205 109712.809738 $898688.1300 $8.1900
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Total 12964 111430.607386 $940817.2100 $8.4400
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Number of Children (Unduplicated) With at Least One Authorization 5352