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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 86106 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 0.175000 $6.5100 $37.2000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 1453 1694 15792.085697 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 2 2 48.885714 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 80 87 20367.919048 $757686.5900 $37.2000
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Subtotal (Total Children Is Unduplicated) 1537 1785 36209.065459 $757693.1000 $20.9300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 483 724 758.003520 $36763.1400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 47 50 79.138922 $4439.7000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 3 3 32.021429 $507.2200 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 189 200 256.281746 $5000.0600 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 18 19 18.794444 $444.8600 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 15 17 23.833333 $349.8700 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 23 26 28.216665 $622.7400 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 14 15 21.733333 $191.4700 $8.8100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.4500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 20 23 28.972222 $837.8800 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 9.150000 $412.4800 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 27 32 34.488888 $476.2900 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 23 25 34.550000 $726.9300 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 0.994444 $60.6600 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 3 3 2.450000 $213.0000 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 137 150 199.285714 $14972.3300 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 24 28 30.396575 $1377.5700 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 11 7.402131 $857.2500 $115.8100
EVAL -96111 DEVELOPMENTAL EVALUATION 114 153 236.430289 $11821.5200 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 19 23 34.036681 $1701.8400 $50.0000
EXIT -EXIT EXIT ASSESSMENT 376 389 461.806454 $23090.3400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 19 26 55.784475 $4183.8400 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 27 27 47.087823 $3531.5900 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 12 12 16.033180 $1202.4900 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 8 8 14.500000 $1087.5000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 10 18.500000 $1387.5000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 13 13 16.030441 $1202.2800 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 9 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 3 4 8.000000 $600.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 43 45 86.362699 $4793.1300 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 19 22 29.058219 $1612.7300 $55.5000
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 2 2 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 278 281 543.318588 $40748.9000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 191 195 352.230135 $26417.2600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 90 91 175.500000 $13162.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 68 68 127.515068 $9563.6300 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 137 137 257.291270 $19296.8500 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 112 115 202.538356 $15190.3700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 566 574 1105.630134 $61362.4800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 276 280 524.399084 $29104.1400 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 153 178 349.500000 $26212.5000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 69 82 161.500000 $12112.5000 $75.0000
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 3 5 27.755555 $3947.6600 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 9 10 48.342857 $2417.1500 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 16 18 122.390478 $6119.5400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 63 80 73.957503 $3802.1600 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 238 279 313.591271 $16121.7400 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 2 2 1.222222 $62.8300 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 24 26 22.476637 $1155.5300 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 2.265753 $116.4800 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.011111 $51.9800 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 99 107 154.379542 $7936.6600 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 3 0.950000 $48.8400 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 12 15 7.927779 $407.5700 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 37 50 32.466665 $1669.1000 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.011111 $51.9800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 63 73 98.373236 $5057.3800 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 3 2.833333 $145.6600 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 3 3 1.277778 $65.6900 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 12 18 10.946196 $562.7500 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 3 3 3.000000 $154.2300 $51.4100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 57 74 54.913490 $2823.0900 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 1.109818 $57.0600 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 15 17 30.020636 $1543.3700 $51.4100
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
SCREEN-T1023 SCREENING 11 11 11.000000 $550.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 338 438 508.793035 $26157.0700 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 5 5 3.310926 $170.2100 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 18 20 13.057936 $671.3100 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.761111 $39.1300 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 5 5 4.128844 $212.2700 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.8200 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 5 6 16.966668 $872.2600 $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 143 192 188.172128 $9673.9500 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 6 4.966666 $255.3300 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 4 4.011111 $206.2100 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 2 1.766666 $90.8200 $51.4100
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 4 4 3.522222 $181.0800 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 11 15 11.338889 $582.9300 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 8 58.900000 $3028.0400 $51.4100
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Subtotal (Total Children Is Unduplicated) 3423 5601 8273.685435 $477529.7200 $57.7200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 154 184 276.924203 $1384621.5000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 38 40 85.176407 $4258.8200 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 2 2 2.000000 $138.7000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 22 27 45.982541 $10650.4900 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4057 6160 6006.805063 $300341.1600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 399 528 343.663772 $17183.1900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 879 1039 918.049888 $22951.2900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5157 8000 30248.979034 $1512449.2100 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 299 394 1498.833335 $74941.6600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 370 520 1450.795604 $36269.9100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4173 6304 18517.477297 $925873.8900 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 222 262 733.891271 $36694.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 186 392 995.859673 $24896.4800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1870 2952 10241.061877 $512053.2000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 151 209 534.707503 $26735.3700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 69 164 445.976190 $11149.4100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5864 8378 23892.125377 $1194606.3400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 315 393 1121.593653 $56079.7100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 393 530 1525.124222 $38128.1500 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 10 10 180.714285 $4517.8600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 44 49 256.404762 $6410.1200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1526 1953 33336.620239 $1666830.9900 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 15.428571 $771.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4184 6429 89642.399222 $4482120.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 347 442 6809.011905 $340450.6300 $50.0000
INTR -T1013 INTERPRETER 759 1080 4480.354407 $224017.7000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 9643 19520 244069.045402 $2928828.5700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 718 989 13486.501577 $970488.7100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 12 12 85.157539 $6127.9300 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 54 69 1193.785714 $68762.0500 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 2 2 53.035714 $3054.8600 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 16 20 218.703175 $15737.8800 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 8 9 122.397620 $8807.7400 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 2 20.285714 $1168.4600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 629 890 11157.148017 $802868.4300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 8 9 139.928570 $10069.2600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 25 32 486.342858 $27993.8900 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 2 14.964285 $861.3500 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 14 18 243.214286 $17501.6800 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 6 8 72.513491 $5218.0700 $71.9600
PHY -97110TLGTHM PT SESSION BY PT ASST 1 2 14.000000 $805.8400 $57.5600
PHY -97110TLHM PT SESSION BY PT ASST 1 2 15.714286 $904.5200 $57.5600
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 2 2 2.011111 $230.8900 $114.8100
SENS -V5050 IN EAR MONAURAL HEARING AID 3 4 3.711111 $852.1100 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 3 4 6.577778 $1510.3300 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 9 11 13.916667 $6390.8300 $459.2200
SENS -V5264 EARMOLD 24 33 70.848323 $1284.4700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1305 1853 24958.488887 $1796012.8700 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 31 42 392.516669 $28245.5200 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 2.857143 $164.5700 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 20 25 390.090477 $28070.9100 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 3 26.747619 $1924.7600 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 3 4 92.642858 $1293.2900 $13.9600
TRAV -TRAVS Travel by mile 3961 8709 1175320.375398 $523017.5800 $0.4500
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Subtotal (Total Children Is Unduplicated) 21069 78720 1706280.482590 $20173408.6400 $11.8200
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Total 86106 1750763.233484 $21408631.4600 $12.2300
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Number of Children (Unduplicated) With at Least One Authorization 22940