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: 04-01-23 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 21444 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 398 407 1895.816654 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 42.142857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 21 21 1839.333333 $68423.2000 $37.2000
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Subtotal (Total Children Is Unduplicated) 421 430 3777.292844 $68423.2000 $18.1100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 137 159 121.224114 $5879.3900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 19 19 16.566668 $929.4000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 9.166667 $145.2000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 2.094444 $40.8600 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 0.761111 $18.0200 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 4.866667 $71.4400 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 8 8 3.922223 $86.5700 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 3.327778 $29.3200 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 5 5 3.566667 $103.1500 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 0.761111 $34.3100 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 13 13 11.011111 $152.0600 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 7.327778 $154.1800 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.166667 $101.4300 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 44 46 46.000000 $3455.9800 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 5.223211 $236.7200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.223211 $25.8500 $115.8000
EVAL -96111 DEVELOPMENTAL EVALUATION 34 48 74.519482 $3725.9800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 4 7.000000 $350.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 137 145 129.493773 $6474.7000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 6 7 23.000000 $1725.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 8 8 14.011111 $1050.8300 $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 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 3.000000 $225.0000 $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 2 3 6.000000 $450.0000 $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 18.000000 $999.0000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 2 0.022222 $1.2300 $55.4400
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 75 75 142.516437 $10688.7400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 39 39 76.500000 $5737.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 24 46.000000 $3450.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 25 25 49.500000 $3712.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 40 40 74.500000 $5587.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 32 32 62.000000 $4650.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 148 150 283.016437 $15707.4200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 52 53 103.500000 $5744.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 23 26 50.000000 $3750.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 12 16 31.000000 $2325.0000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 5.355556 $761.7300 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 4 4 6.033333 $301.6700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 2 12.523810 $626.1900 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 21 24 8.355555 $429.5600 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 64 65 56.538887 $2906.6500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 5.682877 $292.1600 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 1.082192 $55.6400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 29 29 21.997620 $1130.9000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 7 7 1.405555 $72.2600 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 10 10 4.911111 $252.4800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 22 23 20.936507 $1076.3400 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.372222 $19.1300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 5 6 3.315526 $170.4500 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 20 13.291269 $683.3000 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.461111 $23.7100 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 5 5 0.950000 $48.8400 $51.4100
SCREEN-T1023 SCREENING 2 2 2.000000 $100.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 105 111 86.916667 $4468.3900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 10 11 3.266665 $167.9300 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.366667 $70.2600 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.516666 $26.5600 $51.4000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 36 38 19.038987 $978.8000 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.472222 $75.6900 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.277778 $14.2800 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.866667 $95.9700 $51.4100
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Subtotal (Total Children Is Unduplicated) 985 1388 1725.063229 $103640.4400 $60.0800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 52 56 48.295891 $241479.0000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.066667 $710.3100 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1236 1541 1372.431196 $68621.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 144 160 94.650448 $4732.5500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 223 239 179.842229 $4496.0700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1809 2009 2951.132549 $147556.6700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 86 89 111.733336 $5586.6800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 110 117 121.638886 $3040.9700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1432 1593 1895.375401 $94768.8300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 69 74 94.803176 $4740.1700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 57 94 92.932801 $2323.3200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 670 749 957.025788 $47851.2700 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 40 43 41.848413 $2092.4300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 51 43.422218 $1085.5500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1935 2042 2268.928981 $113446.5200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 79 83 74.324603 $3716.2300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 117 121 132.398411 $3309.9600 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 24.000000 $600.0000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 16 41.404760 $1035.1200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 283 297 2083.402784 $104170.1200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1522 1632 9764.076209 $488203.5100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 128 139 885.501589 $44275.0700 $50.0000
INTR -T1013 INTERPRETER 217 276 582.840671 $29142.0300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3655 5056 24907.541223 $298890.3900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 197 216 1283.134929 $92334.2900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 28.926191 $2081.5300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 13 14 64.500001 $3715.1900 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 24.750000 $1425.6000 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 7 7 37.752380 $2716.6700 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 17.404761 $1252.4500 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 2 10.857143 $625.3700 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 176 190 862.317468 $62052.2900 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 11.428572 $822.3900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 5 33.857144 $1948.8100 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 5 5 26.000001 $1870.9500 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 2 7.377777 $530.9000 $71.9600
PHY -97110TLHM PT SESSION BY PT ASST 1 1 10.000000 $575.6000 $57.5600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.066667 $15.3200 $229.7200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.094444 $502.5700 $459.2000
SENS -V5264 EARMOLD 5 5 6.105555 $110.6900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 375 411 2259.214294 $162572.9700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 9 12 47.190475 $3395.8300 $71.9600
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 12 14 54.704763 $3936.5600 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 13.928571 $194.4400 $13.9600
TRAV -TRAVS Travel by mile 1517 2242 116670.466351 $51918.3600 $0.4500
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Subtotal (Total Children Is Unduplicated) 7709 19626 170244.695717 $2110542.5700 $12.4000
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Total 21444 175747.051790 $2282606.2000 $12.9900
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Number of Children (Unduplicated) With at Least One Authorization 8447