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: 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 12631 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 287 291 1520.943648 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 2152.233333 $80063.0800 $37.2000
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Subtotal (Total Children Is Unduplicated) 292 296 3673.176981 $80063.0800 $21.8000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 3.000000 $310.0800 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 107 112 90.108720 $4370.2800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 3.000000 $58.5300 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.411111 $9.7300 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 4.411111 $64.7500 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 0.955555 $21.0900 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 4.411111 $38.8600 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 4.411111 $127.5700 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.411111 $18.5300 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 0.511111 $7.0600 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 5.839682 $122.8700 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 10 10 10.000000 $751.3000 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.411111 $18.6300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.411111 $47.6100 $115.8100
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 26 37 58.165982 $2908.3100 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 5 6.087671 $304.3900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 94 99 79.440249 $3972.0200 $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 4 4 8.000000 $600.0000 $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 2 2 4.000000 $300.0000 $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 7 8 16.000000 $888.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 7 7 14.000000 $1050.0000 $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 4 4 8.166667 $408.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 20.857143 $1042.8600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 4 0.855556 $43.9900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 9 9 7.177778 $369.0100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 2.638890 $135.6700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 2.027778 $104.2500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 0.711111 $36.5600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 1.005556 $51.7000 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 5.863492 $301.4400 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 2 2 0.500000 $25.7100 $51.4100
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 13 13 11.650001 $598.9300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 2 2.000000 $102.8200 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 2.355556 $121.1000 $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
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Subtotal (Total Children Is Unduplicated) 350 454 510.807233 $28557.6800 $55.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 25 26 36.122951 $180614.5000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 859 1025 932.308820 $46615.5500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 84 92 69.269619 $3463.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 157 166 102.909688 $2572.7500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1157 1269 2129.661906 $106483.1000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 50 52 65.287303 $3264.3800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 65 66 85.838890 $2145.9800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1063 1192 1347.218243 $67360.8700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 40 45 57.512695 $2875.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 80 78.196433 $1954.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 403 452 558.961118 $27948.0900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 21 21 24.296030 $1214.7900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 37 53.646031 $1341.1500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1228 1290 1545.611894 $77280.5600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 43 45 49.739683 $2486.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 62 64 98.821829 $2470.5500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 3.071429 $76.7900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 9 28.714284 $717.8500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 60 65 387.596820 $19379.8700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 211 229 1330.432541 $66521.6400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 20 20 138.000002 $6900.0000 $50.0000
INTR -T1013 INTERPRETER 172 226 522.800196 $26140.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2607 3527 18353.380971 $220240.6900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 49 266.978570 $19211.7900 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 7 7 83.142856 $4789.0300 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 3.533333 $254.2600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 40 41 215.056548 $15475.4900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 18.571428 $1068.9700 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 6.535714 $376.1900 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 5 5 12.944444 $931.4900 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.411111 $188.7900 $459.2100
SENS -V5264 EARMOLD 1 1 0.411111 $7.4500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 86 92 556.580156 $40051.5500 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 3 11.928572 $858.3800 $71.9600
TRAV -TRAVS Travel by mile 1064 1678 109154.411451 $48573.7200 $0.4500
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Subtotal (Total Children Is Unduplicated) 4867 11881 138329.904670 $1001857.2200 $7.2400
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Total 12631 142513.888884 $1110477.9700 $7.7900
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Number of Children (Unduplicated) With at Least One Authorization 5242