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 23832 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 278 281 2524.097627 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.400000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 71 71 12189.333334 $453443.2000 $37.2000
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Subtotal (Total Children Is Unduplicated) 351 354 14714.253183 $453458.9100 $30.8200
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 1.000000 $103.3600 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 99 110 98.411222 $4772.9600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 30 30 27.617818 $1549.3500 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 22 22 36.059524 $571.1800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 256 260 257.827778 $5030.2200 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 218 221 219.311111 $3219.4900 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 47 47 41.627778 $918.7300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 221 223 232.466667 $2048.0300 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 218 220 229.466667 $6636.1800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 36 36 16.305555 $225.1800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 224 226 234.288890 $4929.4400 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.261111 $109.6400 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 3 3 2.255556 $169.4600 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 18 18 18.066667 $818.7800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 9.547641 $1105.7200 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 3 3 3.422222 $171.1100 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 8 12.883333 $644.1700 $50.0000
EXIT -EXIT COS Exit 97 107 79.659982 $3982.9900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 15 20 31.180898 $2338.5700 $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 5 5 10.000000 $750.0000 $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 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 20 23 37.940792 $2845.5600 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 34 35 63.111111 $3502.6700 $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 328 335 646.349311 $48476.2100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 102 102 195.522222 $14664.1700 $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 51 52 101.500000 $7612.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 120 120 237.500000 $17812.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 41 41 80.000000 $6000.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 505 512 986.973121 $54777.0200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 209 210 409.450793 $22724.5200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 310 376 738.709524 $55403.2200 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 79 87 170.500000 $12787.5000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 4.800000 $682.7000 $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 54 58 24.734859 $1271.6400 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 3 3 1.533334 $78.8300 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 2 2 0.644444 $33.1300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 137 141 114.830507 $5903.4300 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 1.022222 $52.5500 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 3 3 0.894445 $45.9900 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 14 14 16.025298 $823.8600 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 1.323287 $68.0300 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.197260 $10.1400 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 81 84 97.798415 $5027.8200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 3.283333 $168.7900 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 36 37 12.308068 $632.7600 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 30 32 13.449998 $691.4500 $51.4100
PSTF -97164TLGT PT RE-EVAL EST PLAN CARE 1 1 0.172222 $8.8500 $51.4000
PSTH -97161 PT EVAL LOW COMPLEXITY 59 60 69.598624 $3578.0400 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 1.022222 $52.5500 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.216667 $11.1400 $51.4200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 10 10 6.964916 $358.0700 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 43 44 27.633335 $1420.6400 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 17 19 5.061111 $260.1900 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 29 29 29.000000 $1450.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 4 4.836529 $73.0800 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 156 170 159.396443 $8194.5600 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 3 3 0.866666 $44.5500 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 29 31 18.421432 $947.0600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 5.364687 $275.7900 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 3 3 1.232877 $63.3800 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.216438 $11.1300 $51.4000
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 2 2 1.126027 $57.8900 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 181 197 105.049239 $5400.5800 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 3.400000 $174.7900 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.633333 $83.9700 $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 4 4 1.550000 $79.6900 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 22 24 157.776193 $8111.2600 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 3 3 32.571428 $1674.5000 $51.4100
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Subtotal (Total Children Is Unduplicated) 2301 4657 6502.316010 $359710.6800 $55.3200
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 3 3 1.322223 $56.0800 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 59 65 68.886878 $344434.5000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.133333 $286.6400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 15 15 17.473015 $4047.1000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 886 1062 984.792510 $49239.7300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 71 81 58.715985 $2935.7900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 228 265 222.451525 $5561.3000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1223 1345 2220.016672 $111000.8700 $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 910 999 1411.955682 $70597.8300 $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 408 446 639.914485 $31995.7400 $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 1150 1195 1510.055155 $75502.7400 $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 35 36 850.571434 $21264.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 232 287 1997.621391 $49940.6100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 132 136 977.740475 $48887.0000 $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 4507 4960 32837.937800 $1641896.0800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 276 286 2127.723814 $106386.1600 $50.0000
INTR -T1013 INTERPRETER 235 350 591.998665 $29599.9300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2047 2673 15692.154009 $188305.7400 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 604 665 3858.785759 $277678.1500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 25 27 155.420635 $11184.0600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 61 65 580.771426 $33452.4400 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 3 3 24.285715 $1398.8500 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 86 90 571.960322 $41158.2100 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 14.885714 $1071.1800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 493 543 2920.195438 $210137.2500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 15 15 56.850001 $4090.9300 $71.9600
PHY -97110HM PT SESSION BY PT ASST 33 37 235.876191 $13577.0300 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 27.797619 $1600.0200 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 64 66 364.222224 $26209.4300 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 4 11.590476 $834.0500 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 0.301370 $34.6000 $114.8200
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 3.000000 $688.8300 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 3 3 4.000000 $918.4400 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 13 14 28.081713 $509.1200 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 871 982 5775.303211 $415590.6900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 26 26 163.071430 $11734.6100 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 9 65.695238 $3784.0500 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 0.571429 $32.9100 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 84 90 477.643654 $34371.2000 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 8.928572 $642.5000 $71.9600
TRAV -TRAVS Travel by mile 1021 1565 85941.491819 $38243.9600 $0.4500
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Subtotal (Total Children Is Unduplicated) 6612 18821 164047.129139 $3930877.1200 $23.9600
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Total 23832 185263.698332 $4744046.7000 $25.6100
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Number of Children (Unduplicated) With at Least One Authorization 7392