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: 07-01-22 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 51891 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 0.166667 $6.2000 $37.2100
SCONLY-SCONLY *SERVICE COORDINATION ONLY 1040 1228 9980.974598 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 48.885714 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 19 23 3672.466666 $136615.7600 $37.2000
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Subtotal (Total Children Is Unduplicated) 1062 1254 13702.493645 $136621.9600 $9.9700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 335 491 550.485566 $26698.5500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 11 10.199240 $572.1800 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 13.450000 $213.0500 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 104 110 109.305556 $2132.5500 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 3.650000 $86.4000 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.650000 $9.5400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 1.583333 $34.9400 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 1.144444 $10.0800 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 1.144444 $33.1000 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 0.650000 $29.3000 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 4 6.922221 $95.5900 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 2 2 1.650000 $34.7200 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.450000 $126.0600 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 55 62 62.000000 $4658.0600 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 4 6.733333 $305.1500 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.955556 $110.6700 $115.8200
EVAL -96111 DEVELOPMENTAL EVALUATION 86 116 176.445662 $8822.2900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 16 20 31.031202 $1551.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 268 278 346.281935 $17314.1100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 5 9.000000 $675.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 12 12 22.500000 $1687.5000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC 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 5 5 9.000000 $675.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 6 12.000000 $900.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 74 74 144.291193 $10821.8400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 19 20 40.000000 $3000.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 18 18 36.000000 $2700.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 51 51 99.785714 $7483.9300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 29 29 57.000000 $4275.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 90 90 177.005479 $9823.8100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 25 26 52.000000 $2886.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 52 61 119.000000 $8925.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 22 25 50.000000 $3750.0000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 2 2.411111 $342.9300 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 6 36.842857 $1842.1500 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 13 15 90.123811 $4506.2000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 16 22 13.472223 $692.6100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 72 84 79.011112 $4061.9700 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.211111 $10.8500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 2.827778 $145.3800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 32 38 28.372222 $1458.6100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 4 5 2.883334 $148.2400 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 9 11 6.944444 $357.0100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 14 16 18.392065 $945.5400 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 2 2 0.916667 $47.1300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 4 2.783334 $143.0900 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 17 15.546824 $799.2600 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 6 6 2.361112 $121.3900 $51.4100
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 99 121 128.943652 $6629.0100 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 3 4 2.583334 $132.8100 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.761111 $39.1300 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.005556 $51.7000 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 25 31 19.800001 $1017.9200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 4 4.011111 $206.2100 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 3.000000 $154.2300 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 3 18.614286 $956.9600 $51.4100
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Subtotal (Total Children Is Unduplicated) 1320 1973 2696.133934 $149347.7400 $55.3900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 51 57 74.224201 $371121.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 27 28 58.773233 $2938.6600 $50.0000
AUDE -V5160 DISPENSING FEE BINAURAL 7 9 10.583333 $2451.3000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2773 4177 4127.235219 $206362.4100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 236 310 216.102004 $10805.1000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 592 696 628.056000 $15701.4200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3508 5434 20609.125435 $1030456.4100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 201 264 875.781749 $43789.1000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 257 353 1005.067030 $25126.6900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2875 4303 12453.481675 $622674.2200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 154 180 479.452380 $23972.6100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 139 314 782.039274 $19550.9600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1296 2037 6687.501546 $334375.1300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 101 133 329.105916 $16455.3000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 54 136 382.815079 $9570.3800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3872 5441 15536.094420 $776804.8000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 217 264 741.820636 $37091.0600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 263 350 1024.706749 $25617.6800 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 6 6 140.714285 $3517.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 14 16 108.428573 $2710.7100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 759 867 12322.897618 $616144.9300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 513 708 10016.222615 $500811.1600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 49 60 1057.571431 $52878.5600 $50.0000
INTR -T1013 INTERPRETER 622 900 3786.544886 $189327.2200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 7079 14156 177689.595069 $2132275.1400 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 266 345 4843.226185 $348518.5700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 12.990476 $934.7900 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 21 28 499.500000 $28771.1800 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 52.285714 $3011.6600 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 2 3 29.571429 $2127.9600 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 50.714286 $3649.4000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 287 380 4956.683337 $356682.9200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 62.714285 $4512.9200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 11 13 200.857144 $11561.3300 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 5 6 86.000000 $6188.5500 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 3 34.642857 $2492.9000 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 4 6.733333 $3092.0700 $459.2200
SENS -V5264 EARMOLD 4 8 10.244444 $185.7300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 388 504 6737.061904 $484798.9400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 94.152381 $6775.2100 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.857143 $164.5700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 4 51.000000 $3669.9600 $71.9600
TRAV -TRAVS Travel by mile 2831 6151 854733.460820 $380356.4000 $0.4500
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Subtotal (Total Children Is Unduplicated) 13795 48664 1143608.636094 $8720024.8400 $7.6300
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Total 51891 1160007.263673 $9005994.5400 $7.7600
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Number of Children (Unduplicated) With at Least One Authorization 14749