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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 26183 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 2 2 1.544445 $57.4600 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 319 324 3810.714279 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.733333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 69 70 10438.972223 $388329.7700 $37.2000
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Subtotal (Total Children Is Unduplicated) 391 397 14251.964280 $388387.2300 $27.2500
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 3.000000 $310.0800 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 103 112 95.282389 $4621.2100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 37 37 32.534628 $1825.2000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 27 28 44.372221 $702.8500 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 328 338 332.355556 $6484.2600 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 8 8 6.116666 $144.7800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 274 281 277.420623 $4072.5300 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 49 49 39.650792 $875.0900 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 271 278 281.977777 $2484.2200 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 275 281 286.472222 $8284.7800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 2.083333 $93.9200 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 34 35 19.355554 $267.3000 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 277 283 308.911110 $6499.4900 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 2 3 1.405555 $85.7400 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 3 3 1.505555 $130.8900 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 67 70 69.472222 $5219.4500 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 23 23 17.688888 $801.6600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 4.393378 $508.7900 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 0.622223 $31.1200 $50.0100
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT COS Exit 75 79 59.016440 $2950.8100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 19 21 34.111111 $2558.3300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 23 25 44.794368 $3359.5800 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 8.148336 $611.1300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 12.022222 $901.6700 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 11 11 20.000000 $1500.0000 $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 11 14 24.109590 $1808.2200 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 3 3 3.505556 $262.9200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 36 38 67.494368 $3745.9400 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 7 7 14.000000 $777.0000 $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 321 331 625.060269 $46879.5400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 99 99 193.000000 $14475.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 102 103 203.500000 $15262.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 54 54 107.500000 $8062.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 119 119 236.500000 $17737.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 31 31 60.000000 $4500.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 437 451 867.565748 $48149.9100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 192 197 389.000000 $21589.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 268 330 655.505479 $49162.9100 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 82 99 198.000000 $14850.0000 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 12.714286 $688.7300 $54.1700
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 14 15 16.033334 $2280.4300 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 6 8.871429 $443.5700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 7 18.119047 $905.9600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 74 77 30.793760 $1583.1100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 115 120 96.254263 $4948.4400 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 1.094444 $56.2600 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 4 4 1.811111 $93.1100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 27 27 14.353806 $737.9300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 13.857143 $712.3900 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 3 3 0.770319 $39.6000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 91 97 82.714559 $4252.3600 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 6 7 6.755555 $347.3000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 35 37 11.927320 $613.1800 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.344444 $17.7100 $51.4000
PSTF -97164 PT RE-EVAL EST PLAN CARE 46 47 20.517582 $1054.8100 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 3 1.238889 $63.6900 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 62 64 48.914154 $2514.6700 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 16 16 9.241064 $475.0800 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.066667 $3.4300 $51.4300
PSTH -97163 PT EVAL HIGH COMPLEXITY 50 51 29.005570 $1491.1900 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 27 29 6.866667 $353.0200 $51.4100
SCREEN-T1023 SCREENING 28 28 28.000000 $1400.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.526027 $7.9500 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 174 191 144.306510 $7418.7900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 4 8.112698 $417.0700 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 26 29 9.344440 $480.3800 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 2 0.477778 $24.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 6 6 3.190563 $164.0300 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 4 2.342466 $120.4200 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.347945 $17.8900 $51.4200
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 191 204 114.188533 $5870.4400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 4.077778 $209.6400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 5 2.411111 $123.9500 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 2 2.000000 $102.8200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 1.918494 $98.6400 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 3 0.623288 $32.0400 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 17 19 104.028570 $5348.1200 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 3 3 26.571428 $1366.0400 $51.4100
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Subtotal (Total Children Is Unduplicated) 2521 5013 6555.187221 $351033.7000 $53.5500
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.933333 $39.5800 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 77 85 95.975494 $479878.5000 $5000.0100
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 3.333333 $231.1600 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 23 23 26.391269 $6112.7300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 857 1071 963.296543 $48164.9600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 84 95 82.129673 $4106.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 202 244 201.206645 $5030.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1274 1472 2332.069827 $116603.4300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 53 58 68.220633 $3411.0200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 63 65 71.311109 $1782.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1078 1189 1465.473795 $73273.6200 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 52 56 71.052378 $3552.6000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 42 72 77.472222 $1936.8100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 431 489 624.946419 $31247.2800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 25 25 28.524998 $1426.2400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 18 30 31.373015 $784.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1223 1300 1445.927352 $72296.2400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 50 52 63.209918 $3160.4700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 64 66 70.740476 $1768.5100 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 24 25 604.142859 $15103.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 150 176 1203.569048 $30089.2200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 82 83 511.692863 $25584.6300 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 18.320635 $916.0400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5021 5547 33527.415169 $1676370.8700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 466 480 2955.053195 $147752.6900 $50.0000
INTR -T1013 INTERPRETER 193 275 563.587866 $28179.4000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2430 3191 16469.456323 $197633.4500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 697 774 4483.824618 $322655.9500 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 22 22 144.831746 $10422.1000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 75 80 580.578574 $33441.3200 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 1.571429 $90.5100 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 110 123 576.136517 $41458.8000 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.533333 $110.3400 $71.9600
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 1.428571 $82.2900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 551 622 2995.882548 $215583.5700 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 19 19 84.876190 $6107.6800 $71.9600
PHY -97110HM PT SESSION BY PT ASST 48 50 333.135717 $19175.2900 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 18.000000 $1036.0800 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 88 91 440.498414 $31698.2600 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 3 3 11.900000 $856.3200 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 4 4 0.821156 $94.2700 $114.8000
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 3.033333 $696.4800 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 5 5 3.849999 $1767.9500 $459.2100
SENS -V5264 EARMOLD 21 22 27.235692 $493.7800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 923 1046 6031.261135 $434009.4500 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 31 32 166.428571 $11976.2000 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 8 56.857145 $3274.9700 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 12.857143 $740.5700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 103 117 473.642858 $34083.3700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 5.133333 $369.3900 $71.9600
TRAV -TRAVS Travel by mile 1102 1566 82578.080769 $36747.2500 $0.4500
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Subtotal (Total Children Is Unduplicated) 7334 20773 162611.225181 $4183638.5300 $25.7300
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Total 26183 183418.376682 $4923059.4500 $26.8400
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Number of Children (Unduplicated) With at Least One Authorization 8658