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 22207 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 356 357 1259.661911 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 6.742857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 16 16 1160.096824 $43155.6000 $37.2000
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Subtotal (Total Children Is Unduplicated) 375 376 2426.509925 $43155.9100 $17.7900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 153 179 147.457801 $7151.6800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 19 19 18.092162 $1014.9700 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 5 5 24.854761 $393.7000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.138889 $22.2200 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 6 6 7.972222 $188.7000 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 4 4 3.755555 $55.1300 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 11 11 11.494444 $253.6800 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 7.755555 $55.8400 $7.2000
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 7.277777 $210.4700 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 3.833333 $172.8100 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 10.088888 $139.3300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 9 9 12.872222 $270.8300 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.138889 $8.4700 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.283333 $24.6300 $86.9300
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 27 28 28.000000 $2103.6400 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 4.861111 $220.3100 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.309589 $35.8500 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 18 20 30.505556 $1525.2800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 5 5.327701 $266.3900 $50.0000
EXIT -EXIT EXIT ASSESSMENT 81 83 109.972505 $5498.6300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 10 10 18.500000 $1387.5000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 2.500000 $187.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $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 8 8 15.500000 $1162.5000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 3 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 10 17.500000 $971.2500 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 5.500000 $305.2500 $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 72 72 142.000000 $10650.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 53 53 102.505479 $7687.9100 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 28 28 54.500000 $4087.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 26 26 49.005479 $3675.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 42 42 81.500000 $6112.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 31 32 60.405479 $4530.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 161 164 320.500000 $17787.7500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 77 77 146.916437 $8153.8700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 38 45 89.000000 $6675.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 18 20 39.500000 $2962.5000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 0.455555 $64.7900 $142.2100
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 5 6.206348 $310.3200 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 13.457142 $672.8600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 16 17 5.366668 $275.9100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 59 65 54.688890 $2811.5600 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 3 3 1.149999 $59.1200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 7.950000 $408.7100 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.183562 $9.4400 $51.4200
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 11.096825 $570.4900 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 17 17 8.350000 $429.2700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 1.366667 $70.2600 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.733334 $37.7000 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 9 11 3.466667 $178.2200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 19 20 17.277779 $888.2600 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.083333 $4.2800 $51.3900
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.483333 $24.8500 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 7 3.221919 $165.6400 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 1.202740 $61.8300 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 13 5.250000 $269.9000 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 8 8 1.566667 $80.5400 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 83 92 72.097257 $3706.5100 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.158904 $8.1700 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 6 6 2.411110 $123.9500 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.411111 $72.5400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 43 49 25.869843 $1329.9800 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.337367 $68.7500 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.322222 $67.9700 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 12.461904 $659.6100 $52.9300
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Subtotal (Total Children Is Unduplicated) 952 1366 1867.952313 $111287.7500 $59.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 51 58 66.429213 $332146.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 4.955555 $1147.7900 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1362 1643 1434.640969 $71732.3500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 96 117 75.398428 $3769.9000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 274 291 239.892306 $5997.3200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1924 2113 3117.076333 $155853.8100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 105 111 161.241269 $8062.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 135 143 161.935717 $4048.4000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1543 1726 1987.915189 $99395.8000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 94 95 108.739682 $5436.9800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 47 77 102.655557 $2566.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 675 757 985.830157 $49291.4900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 56 67 50.184913 $2509.2100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 24 35 32.381747 $809.5500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2030 2163 2356.570209 $117828.5400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 103 111 131.557139 $6577.8400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 132 135 186.407938 $4660.2000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 22.857143 $571.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 7 30.857143 $771.4300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 210 221 1710.768252 $85538.4200 $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 1428 1615 9545.719815 $477286.2700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 196 202 1428.434911 $71421.7800 $50.0000
INTR -T1013 INTERPRETER 241 325 731.994442 $36599.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3803 5177 26504.033920 $265040.5100 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 202 230 1453.523007 $104595.6000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 6 6 45.214287 $3253.6200 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 24 26 222.999998 $12844.8100 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 10 10 71.928573 $5175.9800 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 7.000000 $503.7200 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 9.428571 $543.0900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 156 173 967.071427 $69590.4800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 4 4 15.612698 $1123.5000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 6 7 41.714286 $2401.0800 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 5.214286 $300.1400 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 10 10 54.499999 $3921.8300 $71.9600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 5.714286 $328.9200 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.219178 $50.3300 $229.6300
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.511111 $346.9600 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.888889 $1326.6400 $459.2200
SENS -V5264 EARMOLD 7 7 5.934323 $107.5900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 344 393 2304.060306 $165800.3100 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 8 8 37.585713 $2704.6700 $71.9600
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 1.142857 $65.8300 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 8 8 56.909523 $4095.2300 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 18.928571 $264.2400 $13.9600
TRAV -TRAVS Travel by mile 1542 2376 131608.242934 $58565.6700 $0.4500
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Subtotal (Total Children Is Unduplicated) 7817 20465 188123.965627 $2247380.5100 $11.9500
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Total 22207 192418.427865 $2401824.1600 $12.4800
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Number of Children (Unduplicated) With at Least One Authorization 8377