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 26218 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 285 292 828.076180 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 42.142857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 51 51 6708.588886 $249559.5000 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 338 345 7578.807923 $249559.5000 $32.9300
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $206.7200 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 98 114 83.522820 $4050.8700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 32 32 61.261014 $3436.7500 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 10 10 13.414286 $212.4800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 24 26 27.595237 $538.3800 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 9 10.595237 $250.7900 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 18 20 21.595237 $317.0200 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 46 48 37.678573 $831.5700 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 17 19 19.750793 $174.0000 $8.8100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 1.100000 $11.5000 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 25 27 27.650793 $799.6600 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 6 8.523015 $384.2200 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 28 30 88.845237 $1226.9500 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 26 28 33.166666 $697.8300 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 3 3 1.238889 $107.7100 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 327 340 347.403175 $26100.4000 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 22 22 20.055555 $908.9200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 16.152315 $1870.6000 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 31 42 66.308752 $3315.4400 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 4 7.000000 $350.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 106 111 101.083106 $5054.1700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 16 21 37.213699 $2791.0300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 26 26 43.544444 $3265.8300 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 9 10 18.005479 $1350.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 4 4 7.500000 $562.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 13 13 25.000000 $1875.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 7 7 14.000000 $1050.0000 $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 31 31 47.944444 $2660.9100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 6 6 12.000000 $666.0000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 391 402 768.341222 $57625.6100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 145 149 290.785714 $21808.9300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 118 118 228.066667 $17105.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 66 68 133.000000 $9975.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 126 126 249.500000 $18712.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 85 86 171.500000 $12862.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 519 536 1034.345983 $57406.2100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 198 205 400.928571 $22251.5400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 258 322 628.285714 $47121.4300 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 89 106 207.642857 $15573.2200 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 0.211111 $11.4400 $54.1700
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 19 19 18.177779 $2585.4400 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 5 14.257143 $712.8600 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 8 8 35.209525 $1760.4700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 73 85 31.744447 $1632.0000 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.455556 $23.4200 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 155 165 133.839496 $6880.6800 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 1.227778 $63.1200 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 6 6 1.577779 $81.1200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 36 37 19.522070 $1003.6300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 14.513503 $746.1400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 0.511111 $26.2800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 92 94 55.061296 $2830.6900 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 7 7 6.600000 $339.3100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 25 30 8.456350 $434.7500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 54 55 19.900197 $1023.0700 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 3 0.222223 $11.4300 $51.4300
PSTH -97161 PT EVAL LOW COMPLEXITY 58 60 42.500602 $2184.9700 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.052055 $2.6800 $51.4600
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.372222 $19.1300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 18 20 9.759893 $501.7600 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 5 5 3.191781 $164.0900 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 2 2 0.505556 $25.9900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 68 73 46.073236 $2368.6400 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 4 4 1.053805 $54.1800 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 18 21 21.990453 $1130.5200 $51.4100
SCREEN-T1023 SCREENING 44 46 47.233333 $2361.6700 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 1.109133 $16.7600 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 192 208 186.241139 $9574.6500 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 4 2.422222 $124.5300 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 21 23 8.469047 $435.3900 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 2 2 0.538889 $27.7000 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 10 10 5.994444 $308.1700 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 3 3 1.283333 $65.9700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 187 199 87.118950 $4478.7900 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 5.861797 $301.3600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 9 11 3.427777 $176.2200 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.172222 $111.6700 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 8 8 4.677778 $240.4900 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.512100 $26.3300 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 4 4 19.723809 $1014.0100 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 19.714286 $1013.5100 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2689 4398 6219.038199 $393968.8300 $63.3500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 82 87 122.836833 $614184.5000 $5000.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 14 14 11.800001 $2733.1400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 921 1113 995.168994 $49758.5300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 80 88 55.698276 $2784.9300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 226 264 225.630739 $5640.7700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1232 1369 1958.199211 $97909.9800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 55 57 76.912699 $3845.6300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 79 85 82.122221 $2053.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1003 1121 1245.865083 $62293.3000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 42 46 62.419049 $3120.9600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 42 70 60.338890 $1508.4800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 461 522 610.740869 $30537.0300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 19 20 19.459523 $972.9800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 23 44 40.711108 $1017.7700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1287 1355 1428.543655 $71427.2100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 52 54 48.296033 $2414.8000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 84 89 95.965078 $2399.1300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 19 20 362.138094 $9053.4600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 158 221 1460.857152 $36521.4400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 128 130 789.319445 $39465.9800 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4741 5244 31325.706007 $1566284.7000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 634 679 4241.164295 $212058.2000 $50.0000
INTR -T1013 INTERPRETER 201 256 536.162101 $26808.1000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2715 3709 18253.581686 $219042.9200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 653 782 4225.728593 $304083.0700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 12 12 48.504763 $3490.3900 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 73 79 576.582538 $33211.1500 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 6 8 60.714286 $3497.1400 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 100 110 580.612698 $41780.8300 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 16.821428 $1210.4800 $71.9600
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 2.000000 $115.2000 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 616 733 3463.452797 $249229.8700 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 10 10 46.047619 $3313.5800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 47 49 322.523815 $18564.4500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 11.571429 $666.0600 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 84 90 493.841274 $35536.7700 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 13.564286 $976.0900 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 4 4 1.329300 $152.6200 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.072222 $16.5800 $229.5400
SENS -V5060 BEHIND EAR HEARING AID 5 5 4.466667 $1025.6000 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 5 5 4.094444 $1880.2300 $459.2200
SENS -V5264 EARMOLD 19 19 18.060123 $327.4300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 944 1112 6073.321846 $437035.9000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 32 36 163.884921 $11793.1600 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 50.857143 $2929.3700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 109 122 630.536509 $45373.3600 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 5 5 37.047620 $2665.9400 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 3.428571 $47.8600 $13.9600
TRAV -TRAVS Travel by mile 1111 1619 80981.108903 $36036.5900 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 7332 21475 161940.810837 $4298866.0100 $26.5500
-------------------------------------------------------------------------------------------------------------------------------------
Total 26218 175738.656959 $4942394.3400 $28.1200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 8709