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 9920 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 220 220 1447.096034 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 58.288889 $2168.3500 $37.2000
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Subtotal (Total Children Is Unduplicated) 222 222 1505.384923 $2168.3500 $1.4400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 91 100 89.138236 $4323.2100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.388889 $134.0200 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 11.571429 $183.2900 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 4.000000 $78.0400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.427778 $10.1300 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 2.427778 $35.6400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 3 3 3.427778 $75.6500 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 2.427778 $21.3900 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 3 3 2.427778 $70.2100 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.427778 $64.3700 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 4 4 2.638889 $36.4400 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 2.427778 $51.0800 $21.0400
AUDE -V5010 ASSESSMENT FOR HEARING AID 3 3 2.427778 $110.0300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.427778 $49.5400 $115.8200
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 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 -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 1 1 2.000000 $111.0000 $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 1 1 2.000000 $150.0000 $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 3 4 9.800001 $490.0100 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 7 7 36.152381 $1807.6300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 9 9 3.835390 $197.1900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 5.566667 $286.1800 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.038356 $1.9700 $51.4700
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 7 4.438889 $228.2000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 5 5 1.272222 $65.4000 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.171689 $8.8300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 4 4 2.988889 $153.6600 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
SCREEN-T1023 SCREENING 2 2 2.000000 $100.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 21 23 16.844445 $865.9800 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 6.857143 $352.5200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 7.211111 $370.7200 $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 1 1 0.038356 $1.9700 $51.4700
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 11.714286 $602.2300 $51.4100
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Subtotal (Total Children Is Unduplicated) 288 379 437.422447 $23482.9200 $53.6800
EI Services, Class # 03
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 1 1 1.011111 $42.8800 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 18 19 21.405555 $107027.5000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 781 936 841.053726 $42052.8100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 81 88 88.717768 $4435.8800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 129 134 90.254485 $2256.3500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1100 1220 2161.735591 $108086.7000 $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 798 883 1282.373802 $64118.6600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 44 46 72.668253 $3633.4200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 31 51 65.837299 $1645.9300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 366 399 577.255083 $28862.7200 $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 1095 1153 1472.226970 $73611.2600 $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 -T1027TTSC EI GROUP SESSION BY EI PROF 1 1 1.555556 $38.8900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 15 16 136.442860 $6822.1400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 4.034921 $201.7500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 233 257 1782.623828 $89131.1200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 17 21 137.771430 $6888.5600 $50.0000
INTR -T1013 INTERPRETER 173 260 577.756912 $28887.8600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1642 2094 13639.118301 $163669.3200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 42 42 294.876194 $21219.3100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 7.000000 $503.7200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 9 9 81.000001 $4665.5900 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 9.142857 $526.6300 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 4 4 20.717461 $1490.8300 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 30 30 189.150000 $13611.2300 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 5 30.780953 $1771.7500 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.714286 $627.0800 $71.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.427778 $196.4500 $459.2400
SENS -V5264 EARMOLD 1 1 0.427778 $7.7600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 71 75 539.471437 $38820.3400 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 4 15.714287 $905.1400 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 13.214286 $950.9000 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.600000 $331.0200 $71.9600
TRAV -TRAVS Travel by mile 863 1263 69650.515719 $30994.4800 $0.4500
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Subtotal (Total Children Is Unduplicated) 3897 9319 94161.002835 $860759.0200 $9.1400
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Total 9920 96103.810205 $886410.2900 $9.2200
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Number of Children (Unduplicated) With at Least One Authorization 4188