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: 10-01-22 and 12-31-22 Date of Report: 01-23-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 35054 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 363 364 2558.957928 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 63 63 12178.855556 $453053.4300 $37.2000
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Subtotal (Total Children Is Unduplicated) 426 427 14737.813484 $453053.4300 $30.7400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 134 169 145.780127 $7070.3500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 67 67 82.456992 $4625.8400 $56.1000
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 34 34 45.323810 $884.2700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 15 15 25.296033 $598.7600 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 18.596033 $272.9900 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 68 68 56.064755 $1237.3500 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 16 16 21.173811 $152.4500 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 2.466667 $25.7800 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 20 26.390478 $763.2200 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 7 7 17.979366 $810.5100 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 54 54 93.584921 $1292.4100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 29 29 50.049219 $1053.0400 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 5 5 3.316667 $288.3500 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 430 467 471.759686 $35443.3100 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 34 38 29.885694 $1354.4200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 18 19 23.090901 $2674.1700 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 34 42 57.365482 $2868.2800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 6 12.000000 $600.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 50 50 69.537661 $3476.8800 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 14 19 34.243835 $2568.2900 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 28 28 54.005479 $4050.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 17 17 28.010958 $2100.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 14 14 28.000000 $2100.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 9 9 13.005479 $975.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 14 28.000000 $2100.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 5 5 9.000000 $675.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 34 34 60.205479 $3341.4100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 15 17 28.505479 $1582.0600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 374 383 733.845983 $55038.4700 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 221 225 415.605174 $31170.3900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 101 101 196.500000 $14737.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 58 58 110.010958 $8250.8300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 122 123 239.285714 $17946.4300 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 115 116 192.563010 $14442.2300 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 573 579 1117.126936 $62000.5600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 286 289 521.639918 $28951.0200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 395 512 1012.066667 $75905.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 137 169 334.071429 $25055.3600 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 0.822222 $42.6300 $51.8500
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 31 33 41.744443 $5937.2900 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 3 3 7.380952 $369.0500 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 10 10 46.633333 $2331.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 132 137 64.899998 $3336.5000 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 201 231 206.850585 $10634.1800 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 22 23 5.205554 $267.6100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 52 53 30.070396 $1545.9200 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 6 6 5.167123 $265.6400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 5 5 3.011111 $154.8000 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 3 3 1.258523 $64.7000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 157 158 104.785593 $5387.0200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 3.094444 $159.0800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 14 15 6.883333 $353.8700 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 4.000000 $205.6400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 80 84 50.426984 $2592.4500 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 4 1.227778 $63.1200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 94 100 79.662720 $4095.4600 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 0.330518 $16.9900 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 14 15 3.433331 $176.5000 $51.4100
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 1 1 0.238356 $12.2600 $51.4200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 27 28 12.860350 $661.1500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 3 3 1.249315 $64.2300 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.186301 $9.5800 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 86 94 54.308500 $2791.9900 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 8 9 3.166514 $162.7900 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 6 7 1.399771 $71.9600 $51.4100
SCREEN-T1023 SCREENING 61 62 62.300000 $3115.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 4 5.038357 $76.1300 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 373 428 337.886896 $17370.8000 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 26 28 17.557937 $902.6600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 16 17 11.333333 $582.6500 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 5 5 4.211111 $216.4900 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 3 3 1.733333 $89.1100 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 293 329 142.792192 $7340.9200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 6.525190 $335.4600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 7 8 3.033333 $155.9400 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.066667 $54.8400 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 12 12 7.105557 $318.7600 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.455556 $20.4400 $44.8600
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.8600 $44.8600
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 14 14 139.571429 $7387.5000 $52.9300
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Subtotal (Total Children Is Unduplicated) 3467 5795 7903.219740 $499187.3000 $63.1600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 111 120 179.614337 $898068.5000 $4999.9800
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.211111 $14.6400 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 3 3 3.000000 $208.0500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 24 24 27.928115 $6468.7300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1320 1635 1478.575174 $73928.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 110 122 85.401861 $4270.0800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 305 356 331.090240 $8277.2700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1683 1853 2936.156956 $146807.9000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 91 92 134.985717 $6749.2900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 110 118 137.465928 $3436.6500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1355 1496 1942.742869 $97137.2000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 53 56 70.213492 $3510.6800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 67 104 110.470778 $2761.7600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 610 677 918.344457 $45917.2900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 42 44 56.261110 $2813.0500 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 53 59.755552 $1493.8800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1830 1922 2270.601579 $113530.0500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 83 84 131.906349 $6595.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 99 99 135.351589 $3383.7900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 27 30 515.000000 $12875.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 129 143 1351.776197 $33794.4000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1091 1231 9119.350790 $455967.5400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 0.928571 $46.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5465 5960 38900.070777 $1945002.5800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 611 635 4140.238110 $207011.7700 $50.0000
INTR -T1013 INTERPRETER 213 254 751.538812 $37576.9400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3471 4721 26232.948018 $262329.3500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1018 1129 7240.624992 $521035.2300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 25 26 136.723810 $9838.6300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 111 123 995.617851 $57347.6300 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 33.928571 $1954.2800 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 104 110 636.071834 $45771.7000 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 4 4 15.142857 $1089.6800 $71.9600
OCCT -97530TLHM OT SESSION BY OT ASST 2 2 19.285714 $1110.8600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 925 1028 5948.726791 $428070.2600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 21 21 105.726191 $7608.0500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 63 66 523.545239 $30135.2400 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 5 5 38.285715 $2203.7200 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 86 95 502.879372 $36187.1400 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 8 8 59.067858 $4250.5100 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 2 2 7.428571 $427.5900 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 10.000000 $575.6000 $57.5600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 4 4 3.150837 $361.7400 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 6 6 3.989423 $916.0300 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 6 6 7.633333 $1752.6800 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 9 10 9.361112 $4298.8500 $459.2200
SENS -V5264 EARMOLD 42 44 47.654641 $863.9800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1761 1987 12944.844999 $931510.7300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 57 60 366.707937 $26388.2800 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 2.857143 $164.5700 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 10.714286 $617.1400 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 117 125 723.361912 $52053.0600 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 10 10 84.809524 $6102.9000 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 6 6 34.176191 $477.1000 $13.9600
TRAV -TRAVS Travel by mile 1415 2112 125866.872203 $56010.7600 $0.4500
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Subtotal (Total Children Is Unduplicated) 9953 28832 248401.117396 $6609100.9900 $26.6100
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Total 35054 271042.150620 $7561341.7200 $27.9000
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Number of Children (Unduplicated) With at Least One Authorization 10906