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: 04-01-22 and 06-30-22 Date of Report: 08-08-22 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 37639 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 0.250000 $9.2500 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 388 396 474.054745 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 80 80 14138.925395 $523140.2300 $37.0000
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Subtotal (Total Children Is Unduplicated) 469 477 14613.230140 $523149.4800 $35.8000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 203 239 187.169570 $9077.7400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 28 28 73.317460 $4084.5200 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 477 542 620.138094 $14573.2500 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 27 27 26.022222 $611.5200 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 28 28 23.104186 $336.8600 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 114 114 81.904765 $1924.7700 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 23 23 17.194445 $168.3300 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 13 13 13.000000 $127.2700 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 31 31 25.050000 $719.4400 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 18 18 21.000000 $939.9600 $44.7600
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 41 41 35.994444 $493.4800 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 27 28 31.736508 $662.9800 $20.8900
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $60.5700 $60.5700
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.022222 $1.9200 $86.2400
AUDE -V5010 ASSESSMENT FOR HEARING AID 35 38 33.499999 $1507.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 14 14 10.241475 $1177.7600 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 27 32 41.525114 $2076.2600 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 8 16.000000 $800.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 100 101 150.607459 $7530.3700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 42 57 106.434051 $7982.5500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 22 22 37.022222 $2776.6700 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 25 25 43.024962 $3226.8700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 12 12 17.524962 $1314.3700 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 15 15 22.527778 $1689.5900 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 13 14 38.357142 $2876.7900 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 40 40 71.778311 $3983.7000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 13 13 25.000000 $1387.5000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 3 3 6.000000 $333.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 452 457 846.740481 $63505.5600 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 442 445 847.187944 $63539.0900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 145 146 282.066667 $21155.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 62 63 119.000000 $8925.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 132 133 256.008220 $19200.6100 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 149 149 269.450566 $20208.7900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 699 706 1342.232262 $74493.9100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 394 394 742.931519 $41232.7000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 287 312 611.066667 $45830.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 122 133 281.788454 $21134.1400 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 6 6 23.452381 $1172.6200 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 12 37.733334 $1886.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 108 111 71.129317 $3631.1300 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.144444 $7.3700 $51.0300
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 0.283333 $14.4600 $51.0400
OCTH -97165 OT EVAL LOW COMPLEXITY 215 256 229.596042 $11720.9300 $51.0500
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 45 47 30.796239 $1572.1500 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.100000 $5.1100 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 179 184 108.947510 $5561.7700 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 8 8 4.694444 $239.6500 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 5 5 2.598630 $132.6600 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 3.285714 $167.7400 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 74 76 60.304576 $3078.5400 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 2 2 0.605555 $30.9100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 94 112 76.257358 $3892.9200 $51.0500
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 1.116667 $57.0100 $51.0500
PSTH -97161TL PT EVAL LOW COMPLEXITY 3 3 1.674603 $85.4900 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 44 45 27.968569 $1427.8000 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 0.496347 $25.3400 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 120 126 72.342933 $3693.1100 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 4 4 3.438889 $175.5600 $51.0500
PSTH -97163TL PT EVAL HIGH COMPLEXITY 3 3 2.094444 $106.9200 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 4 4 3.977778 $203.0700 $51.0500
SCREEN-T1023 SCREENING 61 61 59.505556 $2975.2800 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 2.235616 $33.5300 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 262 326 327.456811 $16716.6500 $51.0500
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 4 2.572222 $131.3100 $51.0500
SPCH -92521TL EVAL OF SPEECH FLUENCY 3 3 2.394444 $122.2300 $51.0500
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.0500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 22 22 18.374505 $938.0200 $51.0500
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 4 4.000000 $204.2000 $51.0500
SPCH -92522TL EVAL OF SPCH SOUND PROD 4 4 2.727778 $139.2500 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.483333 $24.6700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 371 397 193.588633 $9882.6800 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 4.483333 $228.8700 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 4.133333 $211.0100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 1.587748 $81.0600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 4 5 5.000000 $255.2500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 42 43 33.160622 $1477.3000 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 10 10 89.285714 $4693.7500 $52.5700
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Subtotal (Total Children Is Unduplicated) 3672 6404 8930.698926 $531667.6000 $59.5300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 140 152 162.334462 $811672.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 62 63 138.629416 $6931.4700 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 52.428571 $3610.2300 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 6 6 17.428572 $1200.1300 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 34 34 36.273710 $8342.9100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1282 1564 1345.571836 $67278.9100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 117 144 99.426620 $4971.3300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 361 432 339.309106 $8482.7900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1803 1994 3199.401577 $159970.0600 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 89 94 136.000000 $6800.0200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 132 141 156.681740 $3917.0300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1447 1618 2064.376207 $103218.8900 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 46 49 71.095238 $3554.7700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 71 113 136.129362 $3403.2300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 632 725 1006.166760 $50308.4200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 38 39 51.873018 $2593.6600 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 25 44 52.799994 $1319.9900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1999 2093 2646.123816 $132306.2400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 79 83 128.011903 $6400.5900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 131 135 174.407937 $4360.2000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 20 24 143.071426 $3576.7900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 155 202 954.857126 $23871.4900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1053 1256 9065.687239 $453284.2700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 0.714286 $35.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6099 6686 41619.842409 $2080993.2300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 448 468 2943.576956 $147178.9700 $50.0000
INTR -T1013 INTERPRETER 216 266 648.582386 $32429.1200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3707 4945 26154.274581 $261542.9100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1092 1268 7341.648372 $524487.7500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 19 20 130.283335 $9307.4500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 171 189 1250.901183 $71551.5700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 3 3 27.250001 $1558.6900 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 40 41 188.055553 $13434.7100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 5 5 39.714285 $2837.1900 $71.4400
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 2.285714 $130.7400 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 974 1103 6200.450774 $442960.5800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 24 24 97.107934 $6937.4200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 95 106 582.666660 $33305.2800 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 24.678572 $1410.6200 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 43 43 236.923808 $16925.8500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 11 11 63.509523 $4537.1200 $71.4400
PHY -97110TLGTHM PT SESSION BY PT ASST 2 2 26.857143 $1535.1500 $57.1600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 10.000000 $571.6000 $57.1600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 0.372602 $42.4800 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 5 5 1.476408 $336.6200 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 6 6 7.933333 $1808.7900 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 13 13 12.611111 $5750.6600 $456.0000
SENS -V5264 EARMOLD 40 40 44.852665 $807.3500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1955 2251 13620.532455 $973051.2700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 48 57 258.869048 $18493.5900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 3.771429 $215.7200 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 54 55 385.257143 $27522.8200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 19 20 91.423811 $6531.3200 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 23 27 141.295238 $1961.1800 $13.8800
TRAV -TRAVS Travel by mile 1399 2084 150894.347509 $67147.9900 $0.4500
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Subtotal (Total Children Is Unduplicated) 10615 30758 275230.151863 $6628716.8200 $24.0800
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Total 37639 298774.080929 $7683533.9000 $25.7200
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Number of Children (Unduplicated) With at Least One Authorization 11655