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 21019 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 414 420 4732.455553 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 9.666666 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 16 16 2788.977779 $103749.9800 $37.2000
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Subtotal (Total Children Is Unduplicated) 434 440 7532.644443 $103807.4300 $13.7800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 152 173 144.775583 $7021.6300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 8.079071 $453.2300 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 8 8 9.677778 $153.3000 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 35 36 35.127777 $685.3400 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 0.883333 $20.9100 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 30 31 29.194444 $428.5700 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 10 6.838888 $150.9300 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 27 28 26.550000 $233.9100 $8.8100
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 27 28 26.550000 $767.8300 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 1.783333 $80.3900 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 22 22 13.522221 $186.7400 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 36 37 43.835714 $922.3000 $21.0400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 9 9 9.000000 $676.1700 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 3.767429 $170.7400 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 4 4 1.228539 $142.2700 $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 97 100 73.778769 $3688.9300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 8 14.609589 $1095.7200 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 7 7 14.000000 $1050.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $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 4 4 3.609590 $270.7200 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 0.005556 $0.4200 $75.5900
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 8 8 12.344444 $685.1100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 10.000000 $555.0000 $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 75 76 142.521916 $10689.1500 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 23 23 42.500000 $3187.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 18 18 35.500000 $2662.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 11 11 21.000000 $1575.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 41 41 81.000000 $6075.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 12 12 23.500000 $1762.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 108 114 217.521916 $12072.4700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 55 57 113.000000 $6271.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 29 39 75.500000 $5662.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 9 10 20.000000 $1500.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 10 12 16.322224 $816.1200 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 7 26.714285 $1335.7200 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 17 18 5.086227 $261.4900 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 46 49 44.455555 $2285.4600 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.183333 $9.4200 $51.4000
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 15 8.430160 $433.4000 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 36 36 22.973824 $1181.1000 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 10 10 5.238888 $269.3300 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 17 17 8.472224 $435.5700 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.4100 $51.4100
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.305556 $15.7100 $51.4200
PSTH -97161 PT EVAL LOW COMPLEXITY 17 17 13.277778 $682.6100 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 2.638889 $135.6700 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 21 23 13.522222 $695.1800 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 14 14 3.861111 $198.5000 $51.4100
SCREEN-T1023 SCREENING 6 6 6.000000 $300.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 80 89 65.531639 $3368.9900 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 4 9.857143 $506.7500 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 10 10 3.483333 $179.0800 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 62 63 31.372222 $1612.8400 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.136986 $109.8600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.044444 $53.6900 $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 4 4 29.142857 $1498.2400 $51.4100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.000000 $51.4100 $51.4100
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Subtotal (Total Children Is Unduplicated) 905 1364 1601.879013 $88632.1700 $55.3300
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 2 2 1.761111 $74.6900 $42.4100
ASST -ASST ASSISTIVE TECHNOLOGY 56 61 72.260882 $361303.5000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $694.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1211 1507 1371.556727 $68578.0000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 161 183 147.030553 $7351.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 188 197 124.795205 $3119.8800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1869 2131 3478.838873 $173941.8800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 85 90 124.336507 $6216.8000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 83 85 94.838886 $2370.9700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1546 1705 2143.366650 $107168.2600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 86 90 106.187297 $5309.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 58 97 105.183332 $2629.5800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 637 714 961.086892 $48054.2900 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 37 37 34.380555 $1719.0300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 25 40 45.423014 $1135.5700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1884 2011 2363.390049 $118169.3700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 81 84 91.817061 $4590.8300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 90 92 110.386510 $2759.6700 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 3 3 38.285715 $957.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 4.561906 $114.0500 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 85 88 577.101592 $28855.0700 $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 1740 1942 11714.877802 $585743.9100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 141 145 908.225406 $45411.2600 $50.0000
INTR -T1013 INTERPRETER 221 314 651.524656 $32576.2400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3316 4463 22889.405542 $274672.8600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 206 224 1338.160330 $96294.0000 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 5 6 24.780952 $1783.2400 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 18 19 148.800000 $8570.8700 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 10.428572 $600.6800 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 14 14 76.696827 $5519.1100 $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
PHY -97110 PT SESSION BY LICENSED PT 155 169 886.636508 $63802.3300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 8.142857 $585.9600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 8 9 44.035715 $2534.6900 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 4.714286 $271.3600 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 16 16 84.200001 $6059.0400 $71.9600
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 1.000000 $229.6100 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 1 1 2.000000 $459.2200 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.083333 $497.4700 $459.2100
SENS -V5264 EARMOLD 8 8 5.105555 $92.5600 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 373 407 2330.433351 $167697.9400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 28.428572 $2045.7100 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 5 20.142859 $1160.2300 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 7 7 40.285716 $2898.9700 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.142857 $442.0400 $71.9600
TRAV -TRAVS Travel by mile 1519 2216 119715.463976 $53273.3900 $0.4500
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Subtotal (Total Children Is Unduplicated) 7524 19215 172965.301815 $2299671.2700 $13.3000
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Total 21019 182099.825271 $2492110.8700 $13.6900
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Number of Children (Unduplicated) With at Least One Authorization 8254