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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 104172 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 0.166667 $6.2000 $37.2100
SCONLY-SCONLY *SERVICE COORDINATION ONLY 1076 1269 10406.510314 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 48.885714 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 217 236 112977.084124 $4202747.5200 $37.2000
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Subtotal (Total Children Is Unduplicated) 1292 1508 123432.646819 $4202753.7200 $34.0500
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 2.000000 $206.7200 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 347 512 587.184511 $28478.4500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 97 107 390.787802 $21923.2000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 12 12 27.594444 $437.1000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 674 815 1097.653175 $21415.2100 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 113 120 146.870635 $3476.4300 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 60 67 95.010362 $1394.7500 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 230 265 291.475829 $6432.8900 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 58 66 95.326190 $839.8200 $8.8100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 21 21 25.600000 $267.5200 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 78 89 118.420635 $3424.7300 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 24 31 58.792857 $2650.3800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 111 130 336.248411 $4643.5900 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 77 87 172.470570 $3628.7800 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $61.0000 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 5 5 3.400000 $295.6000 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 813 910 1013.583367 $76150.5100 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 66 76 83.539422 $3786.0100 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 19 25 73.206783 $8478.0800 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 89 120 182.412329 $9120.6200 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 16 20 31.031202 $1551.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 285 296 359.712093 $17985.6200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 53 70 129.490334 $9711.7700 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 80 82 149.055402 $11179.1600 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 36 37 68.005479 $5100.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 14 14 28.000000 $2100.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 13 13 23.511111 $1763.3300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 39 39 77.000000 $5775.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 19 19 32.005479 $2400.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 32 42 79.505479 $5962.9100 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 14 17 32.000000 $2400.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 102 103 178.380060 $9900.0900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 29 29 50.159056 $2783.8200 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 3 3 5.000000 $277.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1334 1357 2608.063452 $195604.8300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 610 622 1179.907326 $88493.0500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 363 366 706.566667 $52992.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 197 201 392.505479 $29437.9100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 479 483 946.685714 $71001.4300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 302 305 559.052129 $41928.9200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1877 1935 3716.405797 $206260.5800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 790 809 1523.442007 $84551.0300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 1019 1275 2482.006196 $186150.4700 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 373 453 898.500000 $67387.5100 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 2 3.233333 $175.1500 $54.1700
MED -99204 OUTPATIENT VISIT, NEW, 45 MINS 1 1 1.911111 $296.1800 $154.9800
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 27 39 119.633330 $17015.4000 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 9 10 99.247619 $4962.3800 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 30 41 380.604766 $19030.2400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 233 339 257.239688 $13224.7100 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 5 5 3.166667 $162.8000 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 2 2 1.350000 $69.4000 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 2 3 3.027778 $155.6600 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 534 686 739.728176 $38029.4600 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 3 3 1.805555 $92.8200 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 17 18 12.222223 $628.3500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 112 131 103.109594 $5300.8900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 13 15 46.166308 $2373.4100 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 8 8 5.027777 $258.4700 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 3 3 2.498630 $128.4500 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 451 516 499.749813 $25692.1400 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 19 21 17.727779 $911.3900 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 55 74 45.464567 $2337.3300 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 6 7 26.834127 $1379.5500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 147 209 204.497026 $10513.2200 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 4 6 4.533334 $233.0600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 194 251 243.255678 $12505.7900 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 3 3 2.501370 $128.6000 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 13 14 31.464286 $1617.5800 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 65 85 67.224966 $3456.0500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 10 10 7.408219 $380.8500 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 3 3 2.205556 $113.3900 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 281 362 270.249777 $13893.5600 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 11 11 7.412405 $381.0700 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 34 46 50.916166 $2617.6000 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 2 2 2.044444 $105.1000 $51.4100
SCREEN-T1023 SCREENING 124 134 136.187823 $6809.3900 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 5 14.910045 $225.2900 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 606 825 907.137498 $46636.0100 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 13 13 11.166667 $574.0800 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 48 67 68.612696 $3527.3700 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 4 5 3.816666 $196.2100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 41 47 50.138356 $2577.6200 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 7 7 7.833333 $402.7100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 8 9 7.366667 $378.7200 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.533333 $27.4200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 690 952 699.166515 $35944.2700 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 20 25 20.884018 $1073.6500 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 19 26 18.783333 $965.6500 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 11 14 10.584170 $544.1300 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 13 14 11.683334 $600.6400 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 59 74 49.015373 $2519.8800 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 3.173212 $163.1400 $51.4100
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 1.584932 $81.4800 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 28 38 526.676189 $27076.4200 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 39.142857 $2012.3400 $51.4100
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Subtotal (Total Children Is Unduplicated) 8625 17241 26910.426869 $1610317.7100 $59.8400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 254 332 706.625250 $3533127.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 49 55 308.089909 $15404.4900 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 6 8 219.887302 $15249.1900 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 11 13 22.772994 $1579.3100 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 68 84 185.483930 $42961.7600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 2968 4505 4450.199432 $222510.6100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 237 311 218.102004 $10905.1000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 827 1070 1021.436686 $25535.9300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3553 5497 20673.492100 $1033674.7400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 201 264 875.781749 $43789.1000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 259 360 1020.650362 $25516.2700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2906 4344 12517.018182 $625851.0400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 155 181 480.785713 $24039.2800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 139 314 782.039274 $19550.9600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1316 2064 6726.823768 $336341.2400 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 101 133 329.105916 $16455.3000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 56 138 393.415079 $9835.3800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3925 5506 15619.945211 $780997.3300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 217 264 741.820636 $37091.0600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 269 357 1039.717860 $25992.9600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 56 84 3445.671427 $86141.7900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 367 796 10397.842856 $259946.0800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 872 1041 14822.957938 $741147.9400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 13021 21075 309339.308950 $15466965.4900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1625 2182 34083.938104 $1704196.8400 $50.0000
INTR -T1013 INTERPRETER 663 980 3974.644886 $198732.2300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 7080 14161 177744.166497 $2132930.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1967 3269 43706.263068 $3145102.8400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 49 64 933.338091 $67163.0100 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 274 420 6823.907530 $393057.0700 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 12 14 204.071428 $11754.5100 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 221 292 3738.152379 $268997.4200 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 19 21 177.330951 $12760.7300 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 8.266667 $476.1600 $57.6000
OCCT -97530TLHM OT SESSION BY OT ASST 2 2 125.571428 $7232.9200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 1700 3017 39209.160311 $2821491.2000 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 40 47 597.129368 $42969.4200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 140 240 3415.561107 $196599.7400 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 8 11 113.409526 $6527.8500 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 181 258 3083.742858 $221906.1200 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 31 37 404.155555 $29083.0400 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 1 36.000000 $2072.1600 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 16.285714 $937.4000 $57.5600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 5 7 9.535006 $1094.7100 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 4 5 4.480518 $1028.7700 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 8 11 15.453424 $3548.2600 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 14 20 23.888889 $10970.2600 $459.2200
SENS -V5264 EARMOLD 44 69 153.000302 $2773.8900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2886 4768 63868.933418 $4596008.5300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 98 134 1814.188092 $130549.0000 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 11 13 141.807142 $8168.0900 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 2 30.285715 $1744.4600 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 233 339 4284.169838 $308288.8700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 42 50 419.771429 $30206.7600 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 20 35 275.161904 $3841.2600 $13.9600
TRAV -TRAVS Travel by mile 2831 6156 854805.746534 $380388.5600 $0.4500
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Subtotal (Total Children Is Unduplicated) 18764 85423 1650580.492207 $40143211.3900 $24.3200
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Total 104172 1800923.565895 $45956282.8100 $25.5200
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Number of Children (Unduplicated) With at Least One Authorization 21446