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 22136 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 417 421 3660.144452 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 21 23 1159.255555 $43124.3000 $37.2000
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Subtotal (Total Children Is Unduplicated) 438 444 4819.400007 $43124.3000 $8.9500
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 161 179 135.819257 $6587.2400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 18 19 21.146043 $1186.2900 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 2.000000 $31.6800 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 24 25 22.961112 $447.9700 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 3.383333 $80.0800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 25 26 24.477777 $359.3300 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 4.955555 $109.3700 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 27 24.155556 $212.8100 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 24 25 23.061111 $666.9300 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 10 10 5.461111 $75.4200 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 28 29 28.894444 $607.9400 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 30 30 29.383333 $2207.5700 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 5 6 3.332648 $151.0300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.172603 $135.8000 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 10 10 11.755479 $587.7800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 12 13 21.042237 $1052.1100 $50.0000
EXIT -EXIT COS Exit 124 134 107.283565 $5364.1600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 4.115068 $308.6300 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 0.755556 $56.6700 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $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 5 6 12.000000 $900.0000 $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 8 9 15.205556 $843.9100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 7.000000 $388.5000 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 0.500000 $27.7500 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 88 90 169.521916 $12714.1500 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 32 32 64.000000 $4800.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 35 35 69.500000 $5212.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 22 22 42.000000 $3150.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 41 42 83.000000 $6225.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 14 14 25.093151 $1881.9900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 160 163 312.021916 $17317.2200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 74 74 143.593151 $7969.4200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 46 55 108.000000 $8100.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 9 11 22.000000 $1650.0000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 2 2 1.222222 $173.8300 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 6 6 7.822222 $391.1100 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 30.390475 $1519.5300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 20 22 8.811112 $452.9800 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 66 69 58.971427 $3031.7100 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 2 2 0.222222 $11.4200 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 2.655555 $136.5200 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 4.857143 $249.7000 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 2.714286 $139.5400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 17 17 9.802054 $503.9200 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 4 4 3.138889 $161.3700 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 5 5 1.027777 $52.8300 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 10 10 3.877778 $199.3600 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 13 13 12.326985 $633.7300 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 0.716667 $36.8500 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 9 9 4.827779 $248.2000 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 17 17 9.561112 $491.5400 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 10 10 2.255556 $115.9600 $51.4100
SCREEN-T1023 SCREENING 5 5 5.000000 $250.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 79 85 64.961643 $3339.6700 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 12 12 3.594444 $184.7900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 2.000000 $102.8200 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.338889 $17.4200 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 59 62 46.989324 $2415.7300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.036910 $104.7200 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.183333 $60.8300 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.285714 $168.9200 $51.4100
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Subtotal (Total Children Is Unduplicated) 1005 1497 1870.182996 $108613.6500 $58.0800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 55 59 80.490183 $402451.5000 $5000.0100
AUDE -V5160 DISPENSING FEE BINAURAL 6 6 4.533333 $1050.0000 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1227 1520 1418.711812 $70935.7500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 126 142 99.788875 $4989.4300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 244 255 171.263237 $4281.5900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1895 2130 3402.190747 $170109.4500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 101 109 149.769052 $7488.4800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 125 131 149.661106 $3741.5200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1527 1705 1994.698437 $99734.8700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 89 91 120.818259 $6040.9300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 56 95 96.265078 $2406.6300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 670 740 1025.639676 $51281.9500 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 48 49 63.896030 $3194.8000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 29 44 58.761112 $1469.0300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1986 2125 2490.145215 $124507.1400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 87 93 97.800002 $4890.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 119 121 159.548410 $3988.7100 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 32.214286 $805.3600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 37 44 200.504766 $5012.6200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 118 125 765.523812 $38276.1900 $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 1652 1813 11247.527013 $562376.1900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 160 167 1098.538097 $54926.9100 $50.0000
INTR -T1013 INTERPRETER 273 391 722.167025 $36108.3500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3632 4959 25220.808484 $302649.5800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 216 240 1491.594447 $107335.1400 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 21.390476 $1539.2500 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 14 15 122.428573 $7051.8900 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 4 4 10.571429 $760.7100 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 12.428571 $894.3600 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 159 170 748.040679 $53829.0200 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 9.530158 $685.7900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 8 56.857143 $3272.6900 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 6.535714 $376.1900 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 14 16 50.071428 $3603.1200 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.246575 $56.6200 $229.6300
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.511111 $346.9600 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.044444 $938.8300 $459.2100
SENS -V5264 EARMOLD 5 5 6.369863 $115.4900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 398 452 2477.932549 $178311.9400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 12 12 56.819048 $4088.6900 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 13.107143 $754.9700 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 6.428571 $370.2900 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 19 20 84.342858 $6069.2800 $71.9600
TRAV -TRAVS Travel by mile 1540 2320 145236.802051 $64630.3700 $0.4500
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Subtotal (Total Children Is Unduplicated) 7786 20195 201288.459735 $2397855.7000 $11.9100
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Total 22136 207978.042738 $2549593.6600 $12.2600
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Number of Children (Unduplicated) With at Least One Authorization 8504