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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 39594 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 2 2 1.544445 $57.4600 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 432 439 4849.052378 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 9.666666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 82 83 12892.088891 $479585.7100 $37.2000
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Subtotal (Total Children Is Unduplicated) 518 526 17752.352380 $479643.1700 $27.0200
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 3.000000 $310.0800 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 176 200 171.680323 $8326.5000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 64 64 64.384627 $3611.9800 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 45 46 69.876908 $1106.8500 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 523 537 526.622222 $10274.4000 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 15 15 15.394443 $364.3800 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 447 457 448.192845 $6579.4700 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 79 79 62.267458 $1374.2400 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 442 452 451.927777 $3981.4800 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 449 458 458.783333 $13268.0100 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 6 6 3.788889 $170.8000 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 64 65 37.899997 $523.4000 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 459 468 500.096031 $10522.0200 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 2 3 1.405555 $85.7400 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 6 6 2.561110 $222.6500 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 101 104 102.450000 $7697.0700 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 41 41 29.961873 $1357.8700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 16 16 8.832876 $1022.9300 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 2 2 0.622223 $31.1200 $50.0100
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 1.000000 $50.0000 $50.0000
EXIT -EXIT COS Exit 102 107 80.278769 $4013.9300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 30 37 64.720700 $4854.0500 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 41 43 80.794368 $6059.5800 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 8.148336 $611.1300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 16.022222 $1201.6700 $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 18 18 34.000000 $2550.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 8 8 14.005479 $1050.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 14 18 31.609590 $2370.7200 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 3 3 3.505556 $262.9200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 45 47 80.194368 $4450.7900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 13 13 22.505479 $1249.0600 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 476 487 928.076706 $69605.7800 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 149 149 288.500000 $21637.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 161 162 319.500000 $23962.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 72 72 142.500000 $10687.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 189 189 372.500000 $27937.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 47 47 91.500000 $6862.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 663 684 1319.653614 $73240.7900 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 276 282 557.500000 $30941.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 424 529 1045.076908 $78380.7700 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 105 131 262.000000 $19650.0000 $75.0000
MED -99202 OUTPATIENT VISIT, NEW, 20 MINS 1 1 12.714286 $688.7300 $54.1700
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 27 28 26.499999 $3769.0800 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 11 13 20.893653 $1044.6900 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 11 12 39.828571 $1991.4400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 124 131 54.004874 $2776.4100 $51.4100
OCTF -97168TL OT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 208 225 183.603198 $9439.0600 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 3 3 1.277777 $65.6900 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 4 4 1.811111 $93.1100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 50 53 29.360374 $1509.4300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 13.857143 $712.3900 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 5 5 2.231430 $114.7200 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.8500 $51.4000
OCTH -97167 OT EVAL HIGH COMPLEXITY 139 145 114.927271 $5908.4300 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 6 7 6.755555 $347.3000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 55 57 19.393986 $997.0400 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.344444 $17.7100 $51.4000
PSTF -97164 PT RE-EVAL EST PLAN CARE 73 74 35.712029 $1835.9700 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 4 4 1.738889 $89.4000 $51.4100
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.305556 $15.7100 $51.4200
PSTH -97161 PT EVAL LOW COMPLEXITY 105 107 82.697486 $4251.4700 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.8200 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.283333 $14.5600 $51.4000
PSTH -97162 PT EVAL MODERATE COMPLEXITY 28 28 16.446848 $845.5300 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 4 4 4.000000 $205.6400 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.066667 $3.4300 $51.4300
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.327778 $16.8500 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 103 108 60.355572 $3102.9100 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 49 52 13.538888 $696.0300 $51.4100
SCREEN-T1023 SCREENING 37 37 37.000000 $1850.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 2 0.591780 $8.9400 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 347 376 279.731684 $14381.0300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 7 7 10.175712 $523.1300 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 46 50 16.233328 $834.5300 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 2 0.477778 $24.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 10 10 6.057229 $311.4000 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 4 2.342466 $120.4200 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 5 5 1.136834 $58.4500 $51.4100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.4100 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 341 362 206.249643 $10603.3000 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 6.214764 $319.5000 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 6 7 3.455555 $177.6500 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 2 2.000000 $102.8200 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 16 16 10.085160 $518.4800 $51.4100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 12.857143 $660.9800 $51.4100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 4 1.117732 $57.4600 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 39 43 217.599998 $11186.8300 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 7 7 67.714285 $3481.1900 $51.4100
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Subtotal (Total Children Is Unduplicated) 4080 8087 10365.530616 $549460.1900 $53.0100
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 3 3 2.694444 $114.2700 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 148 164 183.068414 $915341.5000 $5000.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 3 3 4.333333 $300.5100 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 36 36 38.435561 $8902.4300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1325 1661 1535.499316 $76775.1400 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 161 183 147.030553 $7351.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 319 386 318.886176 $7972.1500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1915 2184 3516.099985 $175804.9400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 85 90 124.336507 $6216.8000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 85 87 99.005553 $2475.1300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1574 1734 2170.733317 $108536.6000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 86 90 106.187297 $5309.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 59 98 106.783332 $2669.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 658 735 977.092446 $48854.5600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 37 37 34.380555 $1719.0300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 43 47.178569 $1179.4600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1918 2046 2384.917828 $119245.7700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 81 84 91.817061 $4590.8300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 94 96 115.647621 $2891.1900 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 37 38 897.142859 $22428.5700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 189 221 1605.845235 $40146.1400 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 135 138 847.384928 $42369.2400 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 4 4 18.320635 $916.0400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 7091 7861 47018.695751 $2350935.0400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 608 626 3853.521457 $192676.0800 $50.0000
INTR -T1013 INTERPRETER 246 343 700.810371 $35040.5200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3316 4464 22891.072209 $274692.8600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1162 1293 7542.984161 $542793.0900 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 31 32 182.974603 $13166.8500 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 106 114 916.283338 $52777.9100 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 11.142858 $641.8300 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 137 152 722.952390 $52023.6800 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.533333 $110.3400 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 4.142857 $238.6300 $57.6000
OCCT -97530TLHM OT SESSION BY OT ASST 1 1 1.428571 $82.2900 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 990 1113 5610.740090 $403748.6600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 27 27 138.804762 $9988.3900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 69 74 490.707147 $28245.1000 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 22.714286 $1307.4400 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 114 119 579.179367 $41677.7600 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 4 4 16.033333 $1153.7600 $71.9600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 9 9 2.709436 $311.0700 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 6 6 4.172145 $957.9600 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 5 5 5.261111 $1208.0000 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 11 11 10.849999 $4982.4900 $459.2200
SENS -V5264 EARMOLD 47 48 46.356694 $840.4400 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1848 2073 11924.527032 $858088.7800 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 48 49 254.964286 $18347.2300 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 11 14 95.857146 $5521.3700 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 12.857143 $740.5700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 129 146 607.842857 $43740.4200 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.276190 $811.4400 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 3 3 17.428572 $243.3000 $13.9600
TRAV -TRAVS Travel by mile 1521 2219 119723.559215 $53276.9900 $0.4500
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Subtotal (Total Children Is Unduplicated) 10825 30981 238796.204235 $6592480.9300 $27.6100
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Total 39594 266914.087231 $7621584.2900 $28.5500
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Number of Children (Unduplicated) With at Least One Authorization 12858