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: 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 11403 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
CASE -CASE NON-TCM CASE MANAGEMENT 1 1 0.422222 $15.7100 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 272 275 2493.086516 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.400000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 688.338889 $25606.2100 $37.2000
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Subtotal (Total Children Is Unduplicated) 278 281 3182.247627 $25621.9100 $8.0500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 96 106 96.224084 $4666.8900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.120548 $62.8600 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 2.461111 $38.9800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 10 10 10.000000 $195.1000 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 8 8 8.000000 $117.4400 $14.6800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 7.000000 $61.6700 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 7.000000 $202.4400 $28.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 7 7.000000 $147.2800 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.261111 $22.7000 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.000000 $90.6400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 1.000000 $115.8100 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 3 3 3.422222 $171.1100 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 7 10.883333 $544.1700 $50.0000
EXIT -EXIT COS Exit 86 94 72.017125 $3600.8500 $50.0000
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 2 2 1.488889 $211.7700 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 4.700000 $235.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 1.657143 $82.8600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 1.511340 $77.7000 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 4.166667 $214.2100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 3.800000 $195.3600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.188889 $9.7100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.933333 $47.9800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 12.285715 $631.6100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.055556 $54.2700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 7.694444 $395.5700 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 15 8.666669 $445.5700 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 13.142858 $675.6700 $51.4100
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Subtotal (Total Children Is Unduplicated) 319 434 511.181037 $28396.0000 $55.5500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 14 16 17.419634 $87098.0000 $4999.9900
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 831 992 925.784028 $46289.3000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 71 81 58.715985 $2935.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 160 169 125.316755 $3132.9300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1194 1315 2194.558737 $109727.9800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 53 56 78.928570 $3946.4300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 53 55 67.288893 $1682.2300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 895 984 1396.108856 $69805.4800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 56 59 80.519051 $4025.9600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 42 71 101.202380 $2530.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 396 434 628.825596 $31441.2900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 24 26 33.221031 $1661.0500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 11 18 36.419047 $910.4800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1131 1175 1489.074998 $74453.7400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 42 42 47.174203 $2358.6900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 65 67 93.466671 $2336.6800 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 70.714286 $1767.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 5.000000 $125.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 96 99 687.680950 $34384.0400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.714286 $85.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 226 255 1766.567071 $88328.3000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 13 92.209525 $4610.4800 $50.0000
INTR -T1013 INTERPRETER 212 312 536.783694 $26839.1800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2047 2673 15692.154009 $188305.7400 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 55 58 414.630953 $29836.8300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 0.695238 $50.0300 $71.9700
OCCT -97530HM OT SESSION BY OT ASST 6 6 42.285713 $2435.6600 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 11.857143 $682.9700 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 4.857143 $349.5200 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.133333 $225.4700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 44 49 257.631549 $18539.1800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 7.571428 $435.8200 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 3.321429 $191.1800 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 3.142857 $226.1600 $71.9600
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 73 80 515.814290 $37117.9800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.714286 $411.2000 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 0.433333 $31.1800 $71.9500
TRAV -TRAVS Travel by mile 1021 1564 85929.063248 $38238.4300 $0.4500
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Subtotal (Total Children Is Unduplicated) 4284 10688 113429.000199 $918015.2100 $8.0900
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Total 11403 117122.428863 $972033.1200 $8.3000
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Number of Children (Unduplicated) With at Least One Authorization 4638