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 12493 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 310 315 3803.203168 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 0.733333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 5 5 536.000000 $19939.2000 $37.2000
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Subtotal (Total Children Is Unduplicated) 318 323 4341.480946 $19996.6600 $4.6100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 99 108 93.860775 $4552.2600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.106849 $118.1900 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 2.000000 $31.6800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 12 12 12.000000 $234.1200 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.083333 $1.9700 $23.6600
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 10 10 9.083333 $133.3400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 1.166666 $25.7500 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 8.083333 $71.2100 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 9 9 8.083333 $233.7700 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.083333 $48.8400 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 6 6 3.138888 $43.3500 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 12 12 19.369047 $407.5200 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 7 7 7.000000 $525.9100 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 1.050000 $47.5900 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.083333 $9.6500 $115.7600
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 72 74 54.516440 $2725.8100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $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 2 2 0.109590 $8.2200 $75.0100
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $222.0000 $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 14 14 26.005479 $1950.4100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 4 4 7.500000 $562.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 14 14 28.000000 $2100.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 2 2 4.000000 $300.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 9 9 16.005479 $888.3100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 7 8 15.500000 $860.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 5 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 5 4.300000 $215.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 5 17.085714 $854.2900 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 1.486226 $76.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 5.505556 $283.0400 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 11 11 7.222223 $371.3000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.833333 $42.8400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 1.172222 $60.2600 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.505556 $128.8100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 1.555555 $79.9700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 3 1.061111 $54.5500 $51.4100
SCREEN-T1023 SCREENING 2 2 2.000000 $100.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 21 23 15.683333 $806.2800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 7.857143 $403.9300 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 2 2 0.594444 $30.5600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 10.255555 $527.2400 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 20.142857 $1035.5500 $51.4100
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Subtotal (Total Children Is Unduplicated) 324 446 470.717818 $24445.6600 $51.9300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 23 26 32.121428 $160606.5000 $4999.9800
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 790 977 871.462522 $43573.2500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 84 95 82.129673 $4106.4800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 127 135 90.882266 $2272.0600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1253 1448 2315.236493 $115761.7600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 53 58 68.220633 $3411.0200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 62 64 69.711109 $1742.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1065 1175 1453.162684 $72658.0700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 52 56 71.052378 $3552.6000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 41 71 75.872222 $1896.8100 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 419 477 616.113087 $30805.6200 $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 1213 1290 1439.338463 $71966.7900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 50 52 63.209918 $3160.4700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 63 65 70.646032 $1766.1500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 29.142858 $728.5700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 58 59 396.800002 $19840.0000 $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 318 340 2160.996825 $108049.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 25 135.247621 $6762.3900 $50.0000
INTR -T1013 INTERPRETER 176 254 527.802151 $26390.1100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2430 3190 16467.789656 $197613.4500 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 56 58 333.246831 $23980.4300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 9.600000 $690.8200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 8 9 43.714285 $2517.9400 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 0.857143 $49.3700 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 5 5 26.666667 $1918.9400 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.533333 $110.3400 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 43 44 289.240475 $20813.7300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 1.714286 $123.3500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 4 4 11.857143 $682.4900 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 5 5 32.590476 $2345.2100 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.083333 $38.2500 $459.0400
SENS -V5264 EARMOLD 1 1 0.083333 $1.5100 $18.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 93 100 665.180955 $47866.4200 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 12.142857 $873.8000 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 4 13.571430 $781.7100 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 19.142858 $1377.5200 $71.9600
TRAV -TRAVS Travel by mile 1101 1564 82572.842673 $36744.9200 $0.4500
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Subtotal (Total Children Is Unduplicated) 4795 11724 111150.224747 $1020939.6600 $9.1900
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Total 12493 115962.423511 $1065381.9800 $9.1900
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Number of Children (Unduplicated) With at Least One Authorization 5170