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: 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 36898 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 0.422222 $15.7100 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 401 404 4645.261127 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 0.977778 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 87 88 14491.377779 $539079.2600 $37.2000
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Subtotal (Total Children Is Unduplicated) 491 495 19138.038906 $539094.9600 $28.1700
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 3 3 2.533333 $261.8400 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 180 201 162.937172 $7902.4700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 57 57 51.340878 $2880.2200 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 36 36 55.721428 $882.6300 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 420 424 417.733333 $8149.9800 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 4 4 2.322222 $54.9700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 363 366 361.866515 $5312.2000 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 81 81 61.838891 $1364.7900 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 367 370 378.011112 $3330.2800 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 362 364 372.522223 $10773.3500 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $45.0800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 63 63 30.400000 $419.8200 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 372 374 387.376192 $8150.4000 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 6 6 13.638889 $1185.7700 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 5 5 3.366667 $252.9400 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 40 41 37.490184 $1699.0600 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 21 21 17.865069 $2068.9500 $115.8100
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 2.785714 $348.2100 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 5 5 6.422222 $321.1100 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 12 15 26.883333 $1344.1700 $50.0000
EXIT -EXIT COS Exit 131 144 109.926422 $5496.3100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 19 25 39.180898 $2938.5700 $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 8 9 18.000000 $1350.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 10.000000 $750.0000 $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 27 31 51.440792 $3858.0600 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 45 46 81.173592 $4505.1300 $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 498 508 980.871227 $73565.3600 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 162 162 314.022222 $23551.6700 $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 82 83 161.000000 $12075.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 178 180 356.500000 $26737.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 63 65 126.000000 $9450.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 750 763 1477.566466 $82004.9500 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 322 324 634.450793 $35212.0200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 463 571 1118.720482 $83904.0500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 112 126 248.500000 $18637.5000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 17 17 16.411111 $2334.1500 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 10 11 26.907937 $1345.4000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 25.585715 $1279.2800 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 105 114 53.645974 $2757.9800 $51.4100
OCTF -97168GT OT RE-EVAL EST PLAN CARE 3 3 1.533334 $78.8300 $51.4100
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 2 2 0.644444 $33.1300 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 233 243 190.899271 $9814.1200 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 5 5 2.244444 $115.3800 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 7 7 1.933334 $99.4000 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 29 30 25.551097 $1313.5800 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 4 4 1.416438 $72.8200 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 11.571429 $594.8900 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.197260 $10.1400 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 134 140 137.442860 $7065.9400 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 6 6 4.666666 $239.9100 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 43 44 14.452512 $743.0100 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 1.288889 $66.2600 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 63 66 29.278050 $1505.1800 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTF -97164TLGT PT RE-EVAL EST PLAN CARE 1 1 0.172222 $8.8500 $51.4000
PSTH -97161 PT EVAL LOW COMPLEXITY 108 112 103.795655 $5336.1000 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 5 5 1.722221 $88.5300 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.216667 $11.1400 $51.4200
PSTH -97162 PT EVAL MODERATE COMPLEXITY 22 24 15.782954 $811.4100 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.366667 $70.2600 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 73 74 52.919049 $2720.5800 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 41 43 12.705554 $653.1800 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 46 46 46.000000 $2300.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 5 4.995433 $75.4800 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 312 338 306.073262 $15735.2000 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 4 1.866666 $95.9600 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 54 56 26.165875 $1345.1900 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 10 10 6.317198 $324.7600 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 4 1.821766 $93.6500 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 4 4 1.134094 $58.3000 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 2 2 1.126027 $57.8900 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 306 329 182.254661 $9369.7000 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 4.905555 $252.1900 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 1.633333 $83.9700 $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 10 11 6.605556 $339.5900 $51.4100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 10.285714 $528.7900 $51.4100
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 2.000000 $102.8200 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 48 51 348.738096 $17928.6200 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 5 5 50.857143 $2614.5600 $51.4100
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Subtotal (Total Children Is Unduplicated) 3750 7573 10339.153896 $566519.3800 $54.7900
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 5 5 2.661112 $112.8600 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 127 136 165.441900 $827210.0000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 7 7 20.366666 $1412.4200 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 26 26 27.350793 $6334.9900 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1344 1641 1545.835198 $77291.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 125 143 102.452366 $5122.6000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 363 426 354.738029 $8868.4600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1863 2046 3463.499491 $173175.0000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 94 99 139.328569 $6966.4300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 82 85 104.830163 $2620.7700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1379 1522 2131.581864 $106579.1100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 84 88 109.724606 $5486.2400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 58 100 132.224606 $3305.6200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 652 719 1071.105753 $53555.3000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 43 46 53.908333 $2695.4200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 32 58.670633 $1466.7600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1817 1896 2384.704365 $119235.2300 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 79 82 94.067058 $4703.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 105 109 151.338103 $3783.4700 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 61 62 1558.571440 $38964.2900 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 302 376 2735.159473 $68379.0900 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 251 261 1730.054761 $86502.7100 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.714286 $85.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6467 7156 46826.204136 $2341308.9500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 384 398 2848.511110 $142425.5300 $50.0000
INTR -T1013 INTERPRETER 292 427 726.212950 $36310.6500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2915 3846 22410.194372 $268922.1600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1059 1167 7017.576251 $504984.6300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 40 44 216.489287 $15578.5600 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 98 103 865.785712 $49869.2700 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 25.035715 $1442.0500 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 97 101 636.004767 $45766.8400 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 3 3 14.885714 $1071.1800 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 907 1002 5475.902597 $394045.8800 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 26 27 146.035716 $10508.7200 $71.9600
PHY -97110HM PT SESSION BY PT ASST 56 63 395.583334 $22769.7500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 6 6 46.654761 $2685.4400 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 96 102 571.679368 $41138.0400 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 5 6 12.209523 $878.6000 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 5 5 0.790259 $90.7300 $114.8200
SENS -V5050 IN EAR MONAURAL HEARING AID 7 7 9.061644 $2080.6300 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 9 9 11.000000 $2525.7100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 7 7 7.766667 $3566.6200 $459.2200
SENS -V5264 EARMOLD 44 45 87.690312 $1589.8300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1708 1928 11468.758774 $825291.6400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 45 45 302.357143 $21757.6000 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 10 15 94.695238 $5454.4500 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 0.571429 $32.9100 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 122 132 737.524609 $53072.2300 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 9.214286 $663.0600 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 15.571429 $217.3800 $13.9600
TRAV -TRAVS Travel by mile 1476 2267 123534.927628 $54973.0400 $0.4500
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Subtotal (Total Children Is Unduplicated) 10051 28830 242654.224299 $6454879.7700 $26.6000
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Total 36898 272131.417101 $7560494.1200 $27.7800
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Number of Children (Unduplicated) With at Least One Authorization 11196