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: 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 21740 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 226 226 1451.807145 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 49 50 9385.455556 $349138.9500 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 275 276 10837.262701 $349138.9500 $32.2200
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 1.344445 $138.9700 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 96 105 91.731843 $4449.0000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 33 33 29.883333 $1676.4500 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 16 17 33.096032 $524.2400 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 288 291 288.944445 $5637.3100 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 2.694445 $63.7800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 228 230 228.694445 $3357.2400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 53 53 38.025400 $839.2300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 234 236 233.561112 $2057.6700 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 231 233 231.694445 $6700.6100 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 6.027778 $271.7300 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 40 40 21.744442 $300.2900 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 237 239 246.419299 $5184.6600 $21.0400
AUDE -92602 REPROGRAM COCHLEAR IMPLT <7 1 1 3.333333 $202.4300 $60.7300
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 3 2.733333 $166.7300 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $86.9400 $86.9400
AUDE -V5010 ASSESSMENT FOR HEARING AID 22 22 18.225647 $825.9800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.581203 $183.1200 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 1 1 0.355556 $17.7800 $50.0100
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 2 4.000000 $200.0000 $50.0000
EXIT -EXIT COS Exit 75 79 59.016440 $2950.8100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 19 21 35.500000 $2662.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 25 27 44.727702 $3354.5900 $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 8 8 14.022222 $1051.6700 $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 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 12 24.000000 $1800.0000 $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 67.027701 $3720.0400 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 8 8 16.000000 $888.0000 $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 319 329 621.060269 $46579.5400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 98 98 192.000000 $14400.0000 $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 53 53 105.500000 $7912.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 120 120 238.500000 $17887.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 29 29 57.000000 $4275.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 435 449 868.994319 $48229.2000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 196 201 397.000000 $22033.5000 $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 84 101 202.000000 $15150.0000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 4 4 2.533333 $360.3100 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 5 6 18.228573 $911.4400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 10 57.580952 $2879.0600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 60 63 29.148479 $1498.5300 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 -1.094444 $-56.2600 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 117 129 110.773810 $5694.8900 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 4 4 3.416667 $175.6500 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 16 16 9.279605 $477.0700 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 13.466927 $692.3400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 0.259512 $13.3400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 68 69 57.504946 $2956.3300 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 26 26 16.505553 $848.5400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 31 32 13.051901 $670.9900 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 3 0.434018 $22.3100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 53 55 52.206240 $2683.9300 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 2.966667 $152.5200 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 13 14 5.347869 $274.9400 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 44 45 25.462711 $1309.0400 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.127778 $6.5700 $51.4200
PSTH -97163TL PT EVAL HIGH COMPLEXITY 18 18 6.755554 $347.3000 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 17 17 17.000000 $850.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.920548 $13.9100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 170 184 166.300110 $8549.4900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 6 6 11.273810 $579.5900 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 19 20 25.461107 $1308.9300 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 2 3 1.483333 $76.2600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 6 2.953196 $151.8200 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.131507 $6.7600 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.209512 $10.7700 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 154 162 92.744453 $4767.9800 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.472222 $127.1000 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.472222 $75.6900 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 3 3.000000 $154.2300 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 5 5 1.699695 $87.3800 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 0.161644 $8.3100 $51.4300
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 18 20 122.847619 $6315.6000 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 13.657143 $702.1100 $51.4100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2168 4505 6227.843332 $339752.6500 $54.5500
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 5 5 3.133334 $132.8900 $42.4100
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 1 1 1.011111 $42.8800 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 75 83 111.676953 $558384.5000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 14 14 15.377779 $1066.4600 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.755556 $191.1000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 7 7 6.277778 $1454.0600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 846 1028 930.887747 $46544.5200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 81 88 88.717768 $4435.8800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 204 242 200.089975 $5002.2400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1132 1254 2191.118924 $109555.8700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 51 53 87.429365 $4371.4700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 71 74 72.944445 $1823.6100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 817 903 1299.168246 $64958.3800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 44 46 72.668253 $3633.4200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 32 52 66.770632 $1669.2600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 377 410 587.855083 $29392.7200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 22 22 25.395240 $1269.7700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 9 15 14.466667 $361.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1117 1175 1499.682527 $74984.0500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 42 43 54.692857 $2734.6400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 85 91 86.477773 $2161.9300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 13 15 460.571428 $11514.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 100 112 779.503185 $19487.5700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 20 21 181.195241 $9059.7600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 13.034921 $651.7500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4356 4808 33345.332427 $1667265.8300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 268 280 1842.461924 $92122.9900 $50.0000
INTR -T1013 INTERPRETER 189 280 614.685483 $30734.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1642 2095 13640.518301 $163686.1200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 535 586 3615.459543 $260168.3200 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 14 14 103.869841 $7474.4900 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 65 68 550.028571 $31681.6300 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 3 3 15.857143 $913.3700 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 132 145 759.672235 $54665.9500 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 2 2 4.800000 $345.4100 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 465 513 2837.363105 $204176.6500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 12 12 66.157144 $4760.6600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 31 33 239.249999 $13771.2400 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 12.392857 $713.3400 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 60 63 393.531752 $28318.5300 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 11.571429 $832.6800 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 0.864536 $99.2500 $114.8100
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.094445 $502.6200 $459.2400
SENS -V5264 EARMOLD 15 15 14.032496 $254.4100 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 778 866 5406.207182 $389030.4900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 19 20 130.171430 $9367.1300 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 10 101.728572 $5859.5700 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 10.857143 $625.3700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 93 103 555.057150 $39941.8700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 6 14.661904 $1055.0700 $71.9600
TRAV -TRAVS Travel by mile 863 1264 69651.915719 $30995.1100 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6232 16959 142793.445119 $3994476.6000 $27.9700
-------------------------------------------------------------------------------------------------------------------------------------
Total 21740 159858.551152 $4683368.2000 $29.3000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 6935