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 19830 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 386 389 4349.883349 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 0.977778 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 18 19 2646.383334 $98445.4600 $37.2000
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Subtotal (Total Children Is Unduplicated) 407 411 6997.666683 $98461.1700 $14.0700
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 1.533333 $158.4800 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 157 175 144.936563 $7029.4500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 8.331507 $467.4000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 10 10 17.034126 $269.8200 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 30 30 29.488889 $575.3300 $19.5100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 28 28 27.966515 $410.5500 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 3.122222 $68.9100 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 26 26.955556 $237.4800 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 25 25 26.466667 $765.4200 $28.9200
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 11 11 8.211112 $113.4000 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 27 27 28.466667 $598.9400 $21.0400
AUDE -92651 AEP HEARING STATUS DETER I&R 2 2 1.261111 $109.6400 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 1 1 1.000000 $75.1300 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 9.669407 $438.2200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.562862 $180.9900 $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 13 22.883333 $1144.1700 $50.0000
EXIT -EXIT COS Exit 112 122 94.283565 $4714.1600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 5 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $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 7 8 14.061111 $780.3900 $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 20 20 38.000000 $2850.0000 $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 13 13 25.500000 $1912.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 159 162 310.521916 $17233.9700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 74 74 145.500000 $8075.2500 $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 1.488889 $211.7700 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 10 11 26.907937 $1345.4000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 17.014286 $850.7100 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 22 23 11.550230 $593.8100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 46 47 40.255066 $2069.5100 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 0.777778 $39.9900 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 2 2 0.733333 $37.7000 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 3.233334 $166.2300 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 28 29 19.355555 $995.0700 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 3 3 1.383333 $71.1200 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 3 3 0.783333 $40.2700 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 15 15 7.877778 $405.0000 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 18 18 24.569048 $1263.0900 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 0.216666 $11.1400 $51.3900
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 5 3.200001 $164.5200 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 12 12 9.963492 $512.2200 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 14 14 4.583333 $235.6300 $51.4100
SCREEN-T1023 SCREENING 6 6 6.000000 $300.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 78 80 66.439191 $3415.6300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 9 9 2.583332 $132.8000 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 1.588889 $81.6900 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.467656 $24.0400 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 47 52 31.793293 $1634.5000 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.111111 $57.1200 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $51.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 2.055556 $105.6800 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 40.857144 $2100.4600 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.571429 $440.6600 $51.4100
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Subtotal (Total Children Is Unduplicated) 943 1440 1892.847307 $108010.9800 $57.0600
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 2 2 1.338889 $56.7800 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 39 42 65.234713 $326173.5000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 4.488889 $1039.7200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1253 1523 1428.027912 $71401.5500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 124 142 101.452366 $5072.6000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 247 257 181.844963 $4546.1400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1816 1997 3426.520919 $171326.0600 $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 1344 1487 2099.914403 $104995.7300 $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 632 699 1053.450198 $52672.5200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 43 46 53.908333 $2695.4200 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 31 58.642855 $1466.0700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1782 1860 2355.885319 $117794.2800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 79 82 94.067058 $4703.3200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 104 108 149.871436 $3746.8000 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 6 6 159.857144 $3996.4300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 15 15 78.252379 $1956.3100 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 153 160 1048.838092 $52441.9000 $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 1519 1722 11512.873843 $575643.3800 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 97 102 641.992058 $32099.6200 $50.0000
INTR -T1013 INTERPRETER 263 382 658.247979 $32912.4000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2915 3846 22410.194372 $268922.1600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 203 219 1538.093651 $110681.1700 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 11 11 35.998810 $2590.4700 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 21 22 140.285714 $8080.4600 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 11.857143 $682.9700 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 5 5 24.187302 $1740.5100 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 3.133333 $225.4700 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 132 143 793.310916 $57086.6500 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 2 2 12.790476 $920.4000 $71.9600
PHY -97110HM PT SESSION BY PT ASST 7 8 65.928570 $3794.8500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 3.321429 $191.1800 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 18 18 100.100001 $7203.2000 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.071233 $16.3500 $229.5000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.266667 $581.6900 $459.2300
SENS -V5264 EARMOLD 6 6 7.426789 $134.6500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 334 360 2246.111901 $161630.1700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 10 10 74.857143 $5386.7200 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 2 12.142857 $699.4300 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 13 13 59.619048 $4290.1800 $71.9600
TRAV -TRAVS Travel by mile 1476 2266 123522.499057 $54967.5100 $0.4500
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Subtotal (Total Children Is Unduplicated) 6929 17979 176726.728390 $2275261.0600 $12.8700
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Total 19830 185617.242380 $2481733.2100 $13.3700
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Number of Children (Unduplicated) With at Least One Authorization 7563