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 25453 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 296 300 1538.716663 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 72 72 9457.096821 $351803.9900 $37.2000
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Subtotal (Total Children Is Unduplicated) 368 372 10995.813484 $351803.9900 $31.9900
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 5.000000 $516.8000 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 111 116 91.580561 $4441.6500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 32 32 30.338889 $1702.0100 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 22 22 19.016666 $301.2200 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 80 83 87.692061 $1710.8700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 9 11 15.558730 $368.2700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 71 74 77.698456 $1140.6100 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 45 47 40.990478 $904.6600 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 66 69 73.292063 $645.7000 $8.8100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.4500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 73 76 79.425397 $2296.9800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 6 11.125397 $501.5300 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 37 39 29.625396 $409.1300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 79 82 88.415872 $1860.2700 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.433333 $124.6100 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 240 245 245.000000 $18406.8500 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 30 30 25.533332 $1157.1600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 5 5 2.017047 $233.5900 $115.8100
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 1.000000 $125.0000 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 27 38 59.165982 $2958.3100 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 5 6.087671 $304.3900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 101 106 85.940249 $4297.0200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 15 20 47.669047 $3575.1800 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 27 27 45.544444 $3415.8300 $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 5 5 8.005479 $600.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 8 15.000000 $1125.0000 $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 49.722222 $2759.5800 $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 392 403 770.341222 $57775.6100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 146 150 291.785714 $21883.9300 $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 65 67 131.000000 $9825.0000 $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 86 87 172.500000 $12937.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 518 536 1034.345983 $57406.2100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 197 204 398.928571 $22140.5400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 255 317 618.285714 $46371.4300 $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 2 2 1.173015 $63.5400 $54.1700
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 14 14 10.599999 $1507.6200 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 8.166667 $408.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 7 7 40.080951 $2004.0500 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 71 75 30.627857 $1574.5900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 137 147 127.540420 $6556.8500 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.394444 $20.2800 $51.4000
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.105556 $5.4300 $51.4300
OCTH -97166 OT EVAL MODERATE COMPLEXITY 25 25 13.047414 $670.7700 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 13.650881 $701.7900 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.142466 $7.3300 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 72 74 61.555958 $3164.6000 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 9 12 11.272222 $579.5000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 22 25 6.706347 $344.7700 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.166667 $8.5700 $51.4200
PSTF -97164 PT RE-EVAL EST PLAN CARE 43 45 19.820550 $1018.9800 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.433333 $22.2800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 51 52 35.329551 $1816.3000 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 16 16 16.972961 $872.5800 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.433333 $22.2800 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 60 64 53.224374 $2736.2600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 4 4 7.000000 $359.8700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 24 26 18.359525 $943.8700 $51.4100
SCREEN-T1023 SCREENING 39 39 39.233333 $1961.6700 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.772603 $11.6700 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 150 163 138.030354 $7096.1600 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 4 3.394444 $174.5100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 18 19 4.395237 $225.9600 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.333333 $17.1400 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 7 7.350000 $377.8600 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 1.106849 $56.9000 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 2.142466 $110.1500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 179 188 83.886479 $4312.6300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 8.354653 $429.5200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 3.016667 $155.0900 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 10 10 5.122451 $263.3500 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.253881 $13.0500 $51.3900
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 13 13 113.561904 $5838.2100 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 6.857143 $352.5200 $51.4100
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Subtotal (Total Children Is Unduplicated) 2511 4409 6318.397267 $387998.5800 $61.4100
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 2 2 2.177778 $92.3600 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 82 87 124.766830 $623834.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.394444 $27.3500 $69.3400
AUDE -V5160 DISPENSING FEE BINAURAL 18 18 17.249999 $3995.4200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 910 1092 1006.336370 $50316.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 84 92 69.269619 $3463.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 226 263 193.487090 $4837.1800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1184 1297 2148.261905 $107413.0900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 50 52 65.287303 $3264.3800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 67 68 87.105556 $2177.6400 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1076 1205 1358.029354 $67901.4300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 40 45 57.512695 $2875.6200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 47 81 79.229766 $1980.7500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 416 465 567.927784 $28396.4200 $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 1238 1300 1554.117450 $77705.8400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 43 45 49.739683 $2486.9900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 65 67 100.888495 $2522.2200 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 12 12 87.928570 $2198.2200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 148 204 788.863476 $19721.5800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 95 100 574.720629 $28736.0700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4632 5099 32542.545951 $1627128.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 658 705 4731.000755 $236550.2300 $50.0000
INTR -T1013 INTERPRETER 190 248 575.621624 $28781.0900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2608 3529 18363.666685 $220364.1200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 644 717 4197.192046 $302030.1900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 17 18 76.431743 $5500.0300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 80 83 724.885711 $41753.4400 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 7 11 62.999999 $3628.8100 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 90 97 537.419046 $38672.6900 $71.9600
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 11.000000 $633.6000 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 531 592 3113.616060 $224055.9500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 13 14 72.495237 $5216.7500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 38 39 292.088093 $16812.6100 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 4 25.035714 $1441.0600 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 87 93 456.787300 $32870.4600 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 3.700000 $266.2500 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 0.605936 $69.5600 $114.8000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 1.433333 $329.1000 $229.6000
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 2.600000 $1193.9700 $459.2200
SENS -V5264 EARMOLD 20 20 14.651141 $265.6200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 881 1004 5936.906715 $427220.1300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 30 32 219.514283 $15796.2600 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 3.857143 $222.1700 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 9.285714 $534.8600 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 106 114 532.568252 $38323.6200 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 2.376190 $170.9900 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 9.571429 $133.6200 $13.9600
TRAV -TRAVS Travel by mile 1065 1680 109163.697165 $48577.8500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7165 20672 190696.790122 $4355505.3900 $22.8400
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Total 25453 208011.000873 $5095307.9600 $24.5000
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Number of Children (Unduplicated) With at Least One Authorization 7979