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 26873 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 298 302 3277.192069 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 86 89 13363.850000 $497135.2200 $37.2000
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Subtotal (Total Children Is Unduplicated) 384 391 16641.042069 $497135.2200 $29.8700
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 116 129 96.758759 $4692.8200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 37 37 31.456937 $1764.7400 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 17 17 14.955556 $236.9000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 147 149 160.461112 $3130.6000 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 7 7 19.000000 $449.7300 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 133 136 147.213699 $2161.1000 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 48 48 42.044445 $927.9200 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 130 133 143.044445 $1260.2200 $8.8100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.4500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 132 135 146.666667 $4241.6000 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 15.000000 $676.2000 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 39 39 42.600000 $588.3100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 136 138 150.633334 $3169.3300 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 8.714286 $757.6200 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 264 269 269.000000 $20209.9700 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 25 26 22.329072 $1011.9500 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 2.088280 $241.8300 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 8 8 8.755479 $437.7800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 8 11.042237 $552.1100 $50.0000
EXIT -EXIT COS Exit 108 118 91.659982 $4582.9900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 14 19 32.180898 $2413.5700 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 27 27 54.000000 $4050.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 17 20 37.500000 $2812.5000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 34 35 63.072222 $3500.5100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 12 12 22.000000 $1221.0000 $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 328 335 643.382644 $48253.7100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 103 103 195.585236 $14668.8900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 105 106 207.285714 $15546.4300 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 50 51 100.500000 $7537.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 119 119 235.500000 $17662.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 42 42 82.000000 $6150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 506 512 987.615978 $54812.7000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 210 211 409.535725 $22729.2300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 311 377 740.709524 $55553.2200 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 79 87 170.500000 $12787.5000 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 0.266667 $14.4500 $54.1800
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 11 11 10.211112 $1452.3400 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 9.661904 $483.1000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 9 9 61.499999 $3075.0100 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 68 71 50.422225 $2592.2200 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.533334 $27.4200 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 151 164 141.569992 $7278.1100 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 3 3 0.450000 $23.1300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 26 26 21.252958 $1092.6200 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 0.189042 $9.7200 $51.4000
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.127778 $6.5700 $51.4200
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 2.769081 $142.3600 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 85 86 64.485386 $3315.1800 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 5 5 4.294444 $220.7800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 24 26 7.361110 $378.4300 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 1.011111 $51.9800 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 38 38 18.138890 $932.5300 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.438889 $22.5600 $51.4100
PSTF -97164TLGT PT RE-EVAL EST PLAN CARE 1 1 0.338889 $17.4200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 62 62 47.426682 $2438.2200 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.394444 $20.2800 $51.4000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 17 17 11.324506 $582.2000 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 3 3 0.254796 $13.0900 $51.3900
PSTH -97163 PT EVAL HIGH COMPLEXITY 62 65 55.781475 $2867.7300 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 6 6 11.615873 $597.1700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 22 24 15.464286 $795.0200 $51.4100
SCREEN-T1023 SCREENING 37 37 37.000000 $1850.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.1100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 185 201 151.042129 $7765.0700 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 2.166667 $111.3900 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 23 23 6.544448 $336.4700 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.427778 $21.9900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 8 5.671994 $291.6000 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.333333 $17.1400 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 4 4 2.768950 $142.3500 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 185 190 93.381978 $4800.7900 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 13.543227 $696.2600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 3.788889 $194.7900 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 4.350000 $223.6300 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.322222 $16.5600 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 16 16 110.242857 $5667.5800 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 3 3 21.857143 $1123.6700 $51.4100
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Subtotal (Total Children Is Unduplicated) 2655 4640 6461.018719 $377318.1000 $58.4000
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.666667 $28.2700 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 94 101 117.020222 $585103.0000 $5000.0200
AUD -92630 AUD REHAB PRELING HEARING LOSS 4 4 3.600000 $249.6600 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 14 14 14.144444 $3276.1300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 877 1076 998.691490 $49934.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 74 82 56.204875 $2810.2400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 234 272 229.375353 $5734.3900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1293 1456 2248.548400 $112427.3300 $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 1095 1233 1390.792092 $69539.5800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 56 58 74.173018 $3708.6600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 47 81 84.931743 $2123.2900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 460 505 666.573803 $33328.6600 $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 1326 1413 1559.284105 $77964.0800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 44 49 47.642063 $2382.1000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 83 83 106.998410 $2674.9600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 18 20 229.785714 $5744.6500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 183 249 1255.268269 $31381.7300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 99 106 719.844452 $35992.2100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4967 5549 34450.714724 $1722535.2900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 531 547 3558.746046 $177937.2100 $50.0000
INTR -T1013 INTERPRETER 244 361 712.846282 $35642.3100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2631 3605 18583.347502 $223000.0800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 672 785 4520.922634 $325325.5100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 23 25 119.004762 $8563.5700 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 90 95 853.285717 $49149.2700 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 6 6 42.999999 $2476.8000 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 81 87 486.384132 $35000.1800 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 3.200000 $184.3200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 598 657 3537.474007 $254556.5400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 11 11 44.823807 $3225.5300 $71.9600
PHY -97110HM PT SESSION BY PT ASST 41 45 346.526188 $19946.0500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 14.678572 $844.8900 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 73 86 492.317463 $35427.1200 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 6 6 11.128571 $800.8100 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.101370 $11.6400 $114.8400
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 2.000000 $918.4400 $459.2200
SENS -V5264 EARMOLD 13 13 17.925419 $324.9900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 955 1112 6409.462725 $461224.6600 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 21 22 151.838096 $10926.2600 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 8 8 47.266666 $2722.5600 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 2.428571 $139.8900 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 97 113 511.263495 $36790.4700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 5 6 20.711111 $1490.3700 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 9.714285 $135.6100 $13.9600
TRAV -TRAVS Travel by mile 1107 1669 109888.985304 $48900.6000 $0.4500
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Subtotal (Total Children Is Unduplicated) 7380 21842 194914.852881 $4492956.8300 $23.0500
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Total 26873 218016.913669 $5367410.1400 $24.6200
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Number of Children (Unduplicated) With at Least One Authorization 8691