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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 39402 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 0.008333 $0.3100 $37.0600
SCONLY-SCONLY *SERVICE COORDINATION ONLY 376 377 1734.422227 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 45.600000 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 85 85 7813.919046 $290677.7800 $37.2000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 465 466 9593.949606 $290678.0900 $30.3000
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 182 209 180.497277 $8754.0900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 60 61 58.461262 $3279.6700 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 25 25 51.276983 $812.2300 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 14 14 13.544445 $264.2500 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 20 20 21.277778 $503.6500 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 17 17 13.941096 $204.6600 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 94 94 71.451587 $1576.9300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 21 21 28.166667 $202.8000 $7.2000
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 2.033333 $21.2500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 24 24 32.527777 $940.7000 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 7 7 8.833333 $398.2100 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 70 70 47.205554 $651.9100 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 34 34 42.344445 $890.9300 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 3 3 1.005556 $61.3400 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 6 6 5.441270 $473.0700 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 436 447 448.344445 $33684.1200 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 35 35 26.058372 $1180.9700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 8 8 13.550565 $1569.3000 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 21 25 38.677778 $1933.8900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 5 5.327701 $266.3900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 96 99 120.043933 $6002.2100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 21 27 48.106849 $3608.0100 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 27 28 52.505479 $3937.9100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 17 17 30.500000 $2287.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 9 9 16.011111 $1200.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 18 18 35.500000 $2662.5000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 6 6 10.000000 $750.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 18 22 41.505479 $3112.9100 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 44 44 81.000000 $4495.5000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 17 18 29.659056 $1646.0700 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 1.000000 $55.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 534 535 1058.572146 $79392.9200 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 217 218 422.180821 $31663.5700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 156 158 309.285714 $23196.4300 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 105 106 206.005479 $15450.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 195 196 381.000000 $28575.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 101 103 198.405479 $14880.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 774 790 1552.000717 $86136.0400 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 319 328 626.658446 $34779.5500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 402 515 994.320482 $74574.0500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 152 177 348.500000 $26137.5000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 26 26 16.099998 $2289.8700 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 7 8 19.953967 $997.7000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 13 13 51.690475 $2584.5300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 119 126 53.282543 $2739.2700 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.683333 $35.1300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 275 306 276.363377 $14207.8700 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 3 3 1.511111 $77.6900 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 9 9 2.811110 $144.5100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 57 57 41.023592 $2109.0300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 7 7 25.205089 $1295.7900 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 3 3 2.061111 $105.9600 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 3 3 11.261209 $578.9400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 135 135 93.431376 $4803.3100 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 8 8 6.600794 $339.3500 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 53 54 16.955552 $871.6700 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 2.450000 $125.9500 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 67 74 31.861109 $1637.9700 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.033333 $1.7100 $51.3600
PSTH -97161 PT EVAL LOW COMPLEXITY 107 120 97.991341 $5037.7700 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 4 4 3.083333 $158.5100 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 4 4 0.944444 $48.5500 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 24 27 23.256101 $1195.6100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 8 8 2.813700 $144.6500 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 2 2 1.405556 $72.2600 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.250000 $12.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 90 95 49.405557 $2539.9500 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 4 4 1.411111 $72.5400 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 47 50 20.968254 $1077.9700 $51.4100
SCREEN-T1023 SCREENING 65 66 67.000000 $3350.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 1.641096 $24.8000 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 393 437 331.787158 $17057.1500 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 8 8 5.047793 $259.5100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 40 41 17.976185 $924.1300 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 3 3 0.883333 $45.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 15 16 10.505099 $540.0700 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 6 6 1.847717 $94.9900 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.500000 $77.1200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 294 333 170.585352 $8769.8400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 16 18 10.176179 $523.1400 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 3.733333 $191.9300 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.105556 $5.4300 $51.4300
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 13 14 21.235770 $952.6400 $44.8600
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.738888 $33.1400 $44.8500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 20 23 149.980952 $7938.4800 $52.9300
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 3 3 18.285715 $967.8600 $52.9300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 3998 6690 9367.567017 $591335.8700 $63.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 151 168 213.127581 $1065635.0000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 5 5 9.739681 $675.4400 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 27 27 23.017961 $5331.4300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1472 1787 1584.021600 $79201.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 97 118 75.401168 $3770.0300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 424 504 468.047846 $11701.2100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1958 2149 3143.920777 $157196.0300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 105 111 161.241269 $8062.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 137 145 164.069050 $4101.7300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1570 1754 2009.909634 $100495.5200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 95 96 109.084126 $5454.2000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 48 78 103.094446 $2577.3700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 696 779 1002.941267 $50147.0400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 57 69 53.432532 $2671.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 25 36 37.181747 $929.5500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2061 2196 2386.212273 $119310.6400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 103 112 133.771425 $6688.5500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 139 142 198.930161 $4973.2600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 16 16 397.961905 $9949.0500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 151 168 1324.676193 $33116.9200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 294 307 2240.108726 $112005.4400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 8.142857 $407.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6489 7211 42916.216053 $2145812.2300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 936 972 6658.135667 $332907.0400 $50.0000
INTR -T1013 INTERPRETER 268 361 781.780156 $39089.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3808 5185 26544.319633 $265443.3600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1171 1301 7519.899973 $541132.3000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 32 35 228.062701 $16411.4000 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 131 140 1104.304755 $63607.9600 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 30.000000 $1728.0000 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 130 137 801.052381 $57643.7500 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 4 4 14.218254 $1023.1400 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 2 2 11.828571 $681.3300 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 1009 1103 5903.304334 $424802.0300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 22 24 100.896030 $7260.4900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 57 64 395.292857 $22753.0500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 17.500000 $1007.3000 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 101 108 566.165873 $40741.3000 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 9 9 66.400000 $4778.1500 $71.9600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 5.714286 $328.9200 $57.5600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 4 4 0.510731 $58.6300 $114.8000
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 1.224734 $281.2300 $229.6200
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.511111 $576.5700 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 12 12 14.077778 $6464.8100 $459.2200
SENS -V5264 EARMOLD 42 42 41.654036 $755.1900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1874 2140 12620.225323 $908152.0000 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 59 64 333.730951 $24015.3000 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 10 56.999997 $3283.2100 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 1.142857 $65.8300 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 126 133 651.825406 $46905.3800 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 11 11 61.636508 $4435.3600 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 7 7 70.057142 $978.0000 $13.9600
TRAV -TRAVS Travel by mile 1547 2383 131648.385790 $58583.5300 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 10796 32246 255017.108113 $6806106.3700 $26.6900
-------------------------------------------------------------------------------------------------------------------------------------
Total 39402 273978.624736 $7688120.3200 $28.0600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 11908