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: 07-01-23 and 09-30-23 Date of Report: 10-10-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 40275 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 432 436 3730.157150 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 13.142857 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 108 113 14887.866666 $553828.6400 $37.2000
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Subtotal (Total Children Is Unduplicated) 541 550 18631.166673 $553828.6400 $29.7300
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 3.000000 $310.0800 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 181 199 154.345894 $7485.7800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 64 65 60.734943 $3407.2300 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 22 22 21.588889 $341.9700 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 234 237 243.694446 $4754.4800 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 17 17 35.353175 $836.8100 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 214 218 226.258143 $3321.4700 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 69 69 51.683335 $1140.6600 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 215 219 225.783334 $1989.1500 $8.8100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 2.000000 $20.9000 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 216 220 227.472223 $6578.5000 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 17.000000 $766.3600 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 58 58 56.483333 $780.0300 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 228 231 240.105556 $5051.8200 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 2.633333 $160.6300 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 4 4 12.236508 $1063.8400 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 393 400 400.149999 $30063.2600 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 49 51 41.797869 $1894.2800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 7.849772 $909.0700 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 10 10 11.755479 $587.7800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 14 17 25.567808 $1278.3900 $50.0000
EXIT -EXIT COS Exit 143 156 122.926422 $6146.3100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 20 26 42.295966 $3172.2000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 34 34 68.000000 $5100.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 9 10 20.000000 $1500.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 8.755556 $656.6700 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 11 11 22.000000 $1650.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 24 28 51.000000 $3825.0000 $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 46 47 82.279148 $4566.5000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 16 16 29.000000 $1609.5000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 2 2 2.500000 $138.7500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 498 508 977.904560 $73342.8600 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 161 161 310.085236 $23256.3900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 163 164 321.785714 $24133.9300 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 83 84 164.000000 $12300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 177 179 354.500000 $26587.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 64 66 125.593151 $9419.4900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 752 763 1471.137894 $81648.1700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 322 324 630.628876 $34999.9000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 464 572 1120.720482 $84054.0500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 112 126 248.500000 $18637.5000 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 0.266667 $14.4500 $54.1800
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 24 24 23.444446 $3334.5300 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 8 8 15.850793 $792.5400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 11 11 65.066666 $3253.3400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 118 127 76.738892 $3945.1600 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.533334 $27.4200 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 267 289 236.640811 $12165.7000 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.366667 $18.8500 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 5 5 0.905555 $46.5500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 42 42 37.623039 $1934.2000 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 5.046185 $259.4200 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 1.127778 $57.9800 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 3 3 2.906067 $149.4000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 137 141 103.768339 $5334.7200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 8 8 17.576190 $903.5900 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 37 39 10.783333 $554.3700 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 1.261111 $64.8300 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 65 65 27.738890 $1426.0600 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.438889 $22.5600 $51.4100
PSTF -97164TLGT PT RE-EVAL EST PLAN CARE 1 1 0.338889 $17.4200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 104 108 80.511906 $4139.1200 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 3 3 1.716667 $88.2600 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 2 2 0.888888 $45.6900 $51.4000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 36 37 25.216733 $1296.4000 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 7 7 1.498631 $77.0400 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.183333 $9.4200 $51.4000
PSTH -97163 PT EVAL HIGH COMPLEXITY 100 104 75.131474 $3862.5100 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 8 8 13.115873 $674.2800 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 43 46 19.497621 $1002.3800 $51.4100
SCREEN-T1023 SCREENING 63 64 63.566667 $3178.3400 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.1100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 357 384 295.574822 $15195.5000 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 5 5 3.418722 $175.7600 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 48 50 14.250002 $732.6000 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.427778 $21.9900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 12 13 9.010427 $463.2300 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 3 3 3.333333 $171.3700 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 6 7 4.041173 $207.7600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 324 335 195.896756 $10071.1000 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 16.120548 $828.7600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 4.238889 $217.9200 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.8200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 14 14 22.223809 $1142.5200 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.322222 $16.5600 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 35 35 247.023810 $12699.4900 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 5 5 35.000000 $1799.3500 $51.4100
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Subtotal (Total Children Is Unduplicated) 4188 7392 10032.739669 $584145.5800 $58.2200
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.666667 $28.2700 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 164 177 221.284300 $1106424.0000 $5000.0100
AUD -92630 AUD REHAB PRELING HEARING LOSS 8 8 15.511111 $1075.6900 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 27 27 25.949999 $6010.5200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1319 1643 1539.819098 $76991.1300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 127 143 100.788875 $5039.4300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 368 431 353.028525 $8825.7300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1941 2177 3434.796300 $171739.7200 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 101 109 149.769052 $7488.4800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 126 132 153.527773 $3838.1800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1556 1734 2017.904787 $100895.1900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 89 91 120.818259 $6040.9300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 57 96 96.326189 $2408.1500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 692 762 1045.034121 $52251.6700 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 48 49 63.896030 $3194.8000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 30 45 59.244445 $1481.1100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2016 2155 2516.922993 $125846.0300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 87 93 97.800002 $4890.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 121 123 159.948410 $3998.7100 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 30 34 513.214287 $12830.3600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 240 336 1754.201611 $43855.0700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 189 199 1249.909530 $62495.4700 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 2.142857 $107.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7040 7823 48428.115958 $2421405.1200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 701 724 4724.317474 $236215.8000 $50.0000
INTR -T1013 INTERPRETER 302 436 839.989139 $41999.4600 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3639 4970 25370.379913 $304444.4400 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1154 1328 7934.831376 $570990.3100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 38 40 191.369842 $13770.9700 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 125 131 1180.942860 $68022.3200 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 9 9 59.321428 $3416.9100 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 97 103 563.384133 $40541.0800 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 12.428571 $894.3600 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 3.200000 $184.3200 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 1035 1150 6084.299010 $437826.0600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 23 23 103.453965 $7444.5500 $71.9600
PHY -97110HM PT SESSION BY PT ASST 67 72 556.002380 $32003.5000 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 20.392858 $1173.8100 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 100 120 625.446036 $45007.0100 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 8 8 31.842857 $2291.4100 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 1.401370 $160.8900 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 6 6 4.835464 $1110.2800 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 5 5 4.511111 $1035.7900 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 11 11 12.511110 $5745.3000 $459.2200
SENS -V5264 EARMOLD 45 45 62.523210 $1133.5400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1917 2195 12775.856795 $919350.1800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 46 47 278.204762 $20019.6000 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 13 15 79.445238 $4576.0400 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 8.857142 $510.1700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 132 157 735.696832 $52940.6500 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 7 33.568254 $2415.5700 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 4 4 27.571428 $384.9000 $13.9600
TRAV -TRAVS Travel by mile 1546 2327 145334.516337 $64673.8600 $0.4500
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Subtotal (Total Children Is Unduplicated) 10933 32333 271781.722074 $7109443.9600 $26.1600
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Total 40275 300445.628416 $8247418.1800 $27.4500
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Number of Children (Unduplicated) With at Least One Authorization 12943