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: 07-01-23 and 09-30-23 Date of Report: 10-10-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 13302 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 293 297 3241.080958 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 8.700000 $323.6400 $37.2000
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Subtotal (Total Children Is Unduplicated) 296 300 3249.780958 $323.6400 $0.1000
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 112 125 94.204649 $4568.9500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 4.084932 $229.1600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.8400 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 6 6 6.000000 $117.0600 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 6.000000 $88.0800 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.933333 $86.8100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 6.000000 $52.8600 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 6.000000 $173.5200 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 7 8.000000 $168.3200 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 10 10 10.000000 $751.3000 $75.1300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 8 8 8.755479 $437.7800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 7 9.042237 $452.1100 $50.0000
EXIT -EXIT COS Exit 97 105 84.017125 $4200.8500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 3 6.000000 $333.0000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 0.500000 $27.7500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 23 23 46.000000 $3450.0000 $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 9 9 18.000000 $1350.0000 $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 12 12 24.000000 $1800.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 28 28 56.000000 $3108.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 19 21 42.000000 $3150.0000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 0.488889 $69.5400 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.633333 $81.6700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 30.390475 $1519.5300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 3 0.422223 $21.7100 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 9.666666 $496.9600 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.111111 $5.7100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 2.714286 $139.5400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 6 6 2.611110 $134.2300 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.183333 $9.4200 $51.4000
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 1.427778 $73.4000 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 5.571429 $286.4300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.177778 $60.5500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 5 5 2.722223 $139.9500 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.183333 $9.4200 $51.4000
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 16 16 11.372221 $584.6400 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 0.733334 $37.7000 $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 12 13 5.322222 $273.6100 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.183333 $60.8300 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 364 488 553.452832 $31054.1700 $56.1100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 26 28.907990 $144540.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 822 1002 937.383008 $46869.2600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 74 82 56.204875 $2810.2400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 162 171 122.868361 $3071.7200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1266 1428 2228.142846 $111407.0600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 61 67 79.075399 $3953.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 86 88 101.444439 $2536.1000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1084 1222 1380.030188 $69001.4800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 56 58 74.173018 $3708.6600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 80 84.870632 $2121.7600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 451 496 660.940470 $33046.9900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 30 30 39.251585 $1962.5700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 34 48.438890 $1210.9800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1310 1397 1545.034106 $77251.5900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 44 49 47.642063 $2382.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 81 81 106.598410 $2664.9600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 2.500000 $62.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 12 14 60.714287 $1517.8600 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 66 71 496.153972 $24807.6900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 240 263 1682.294841 $84114.7100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 22 22 139.571430 $6978.5600 $50.0000
INTR -T1013 INTERPRETER 221 323 607.774168 $30388.7100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2629 3601 18515.490359 $222185.8000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 57 62 316.328571 $22763.0200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 2.533333 $182.3000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 4 4 24.857143 $1431.7700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 55 59 234.397025 $16867.2300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 4.285714 $308.4000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 4 4 28.714285 $1652.8000 $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 3 4 13.214286 $950.8900 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 85 97 453.245240 $32615.5500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 2.733333 $196.6900 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 4 5 24.280952 $1747.2500 $71.9600
TRAV -TRAVS Travel by mile 1105 1666 109847.413875 $48882.1000 $0.4500
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Subtotal (Total Children Is Unduplicated) 4992 12514 140007.044808 $1007262.0700 $7.1900
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Total 13302 143810.278598 $1038639.8800 $7.2200
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Number of Children (Unduplicated) With at Least One Authorization 5338