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: 07-01-22 and 06-30-23 Date of Report: 07-25-23 Page: 1
Eligibility Filter: Program Patients
With the filters selected there were 87080 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 0.008333 $0.3100 $37.0600
SCONLY-SCONLY *SERVICE COORDINATION ONLY 1452 1669 18852.267446 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 49.419047 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 81 87 23100.596827 $859342.2100 $37.2000
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Subtotal (Total Children Is Unduplicated) 1536 1760 42002.291653 $859342.5200 $20.4600
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 1 1 3.000000 $310.0800 $103.3600
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 479 708 777.110700 $37689.8800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 56 63 99.239453 $5567.3200 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 8 8 36.376985 $576.2100 $15.8400
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 73 81 108.952379 $2125.6600 $19.5100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 11 14 17.427777 $412.5100 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 29 34 44.888888 $658.9700 $14.6800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 20 27 26.044443 $574.8000 $22.0700
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 32 48.927777 $431.0500 $8.8100
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $10.4500 $10.4500
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 27 35 50.955555 $1473.6300 $28.9200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 6 8.927778 $402.4700 $45.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 44 49 48.955557 $676.0800 $13.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 41 48 69.689682 $1466.2700 $21.0400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 2 1.638888 $99.9700 $61.0000
AUDE -92651 AEP HEARING STATUS DETER I&R 4 4 3.872222 $336.6500 $86.9400
AUDE -92652 AEP THRSHLD EST MLT FREQ I&R 170 186 235.285714 $17677.0100 $75.1300
AUDE -V5010 ASSESSMENT FOR HEARING AID 23 29 29.480515 $1336.0500 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 13 8.550532 $990.2300 $115.8100
BEHV -BEHV BEHAVIORAL ASSESSMENT 2 2 1.428571 $178.5800 $125.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 113 150 232.326484 $11616.3300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 22 26 37.124352 $1856.2200 $50.0000
EXIT -EXIT EXIT ASSESSMENT 341 353 407.477687 $20373.9000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 19 25 52.266667 $3920.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 27 27 49.011111 $3675.8300 $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 41 44 84.973810 $4716.0500 $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 279 282 545.318588 $40898.9000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 189 193 350.052053 $26253.9000 $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 69 69 130.515068 $9788.6300 $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 112 115 200.942466 $15070.6700 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 568 576 1109.130134 $61556.7300 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 273 277 519.303194 $28821.3200 $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 4 6 28.811111 $4097.8000 $142.2300
NUTR -97802 NUTRITIONAL EVAL, INITIAL 12 14 54.384127 $2719.2100 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 11 12 121.519048 $6075.9600 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 67 89 77.632543 $3991.1000 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 238 286 321.452384 $16525.8900 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.288889 $14.8500 $51.4100
OCTH -97165TL OT EVAL LOW COMPLEXITY 3 4 3.677778 $189.0800 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 29 32 25.685465 $1320.4900 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 22.408610 $1152.0300 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.011111 $51.9800 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 23.285714 $1197.1200 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 96 102 103.259213 $5308.5800 $51.4100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 6 6 4.794444 $246.4800 $51.4100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 23 25 14.722222 $756.8700 $51.4100
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.4100 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 38 53 32.655558 $1678.8300 $51.4100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.011111 $51.9800 $51.4100
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.200000 $10.2800 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 62 75 94.531171 $4859.8500 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 4 2.694445 $138.5200 $51.4100
PSTH -97161TL PT EVAL LOW COMPLEXITY 2 2 1.066667 $54.8400 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 13 20 13.351751 $686.4200 $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 64 76 56.585713 $2909.0700 $51.4100
PSTH -97163GT PT EVAL HIGH COMPLEXITY 2 2 1.109818 $57.0600 $51.4100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 29 34 17.550002 $902.2600 $51.4100
SCREEN-T1023 SCREENING 8 8 8.000000 $400.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 327 432 431.353897 $22175.9400 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 5 3.727593 $191.6400 $51.4100
SPCH -92521TL EVAL OF SPEECH FLUENCY 30 36 22.502381 $1156.8500 $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 4.805556 $247.0600 $51.4100
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 3.000000 $154.2300 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 4 5 3.966668 $203.9300 $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 152 203 190.573685 $9797.4200 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 8 5.972830 $307.0600 $51.4100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 8 7.838889 $403.0000 $51.4100
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.844444 $43.4100 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 6 6 5.450000 $280.1800 $51.4100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 6 6 58.900000 $3028.0500 $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) 3341 5639 8199.494089 $475765.9200 $58.0200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 165 202 330.374268 $1651871.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 9 9 42.906567 $2145.3300 $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 13 17 30.644443 $7097.8300 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 4081 6155 6208.652982 $310433.4800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 390 515 362.866862 $18143.3600 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 883 1042 910.650893 $22766.3200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5428 8139 31100.974664 $1555048.9600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 299 400 1576.655559 $78832.7800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 344 469 1407.478936 $35186.9900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 4492 6618 18804.757646 $940237.8300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 233 303 907.507141 $45375.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 178 366 940.961277 $23524.0500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1927 3026 10533.014882 $526650.8600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 136 209 532.846389 $26642.3100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 77 174 488.466672 $12211.6800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5982 8401 23682.707104 $1184135.3600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 290 371 1124.904761 $56245.2400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 355 467 1478.795650 $36969.9300 $25.0000
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 8 9 154.357142 $3858.9300 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 61 67 333.080946 $8327.0200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 864 1086 20563.596422 $1028179.8600 $50.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 21.142857 $1057.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4280 6672 92978.159821 $4648908.8200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 512 664 9844.966649 $492248.4700 $50.0000
INTR -T1013 INTERPRETER 753 1080 4640.582979 $232029.1200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 10107 20211 249788.138868 $2997458.1200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 667 935 13456.779740 $968350.1100 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 14 14 133.443254 $9602.5700 $71.9600
OCCT -97530HM OT SESSION BY OT ASST 57 74 1357.901583 $78215.1200 $57.6000
OCCT -97530HMGT OT SESSION BY OT ASST 4 5 63.500000 $3657.6000 $57.6000
OCCT -97530TL OT SESSION BY LICENSED OT 26 30 385.450793 $27737.0400 $71.9600
OCCT -97530TLGT OT SESSION BY LICENSED OT 7 8 120.759524 $8689.8600 $71.9600
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 2 20.285714 $1168.4600 $57.6000
PHY -97110 PT SESSION BY LICENSED PT 545 768 10134.391471 $729270.9300 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 8 8 141.415871 $10176.2900 $71.9600
PHY -97110HM PT SESSION BY PT ASST 22 34 546.571429 $31460.6500 $57.5600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 32.678571 $1880.9800 $57.5600
PHY -97110TL PT SESSION BY LICENSED PT 33 37 396.801586 $28553.8500 $71.9600
PHY -97110TLGT PT SESSION BY LICENSED PT 2 3 42.158730 $3033.7400 $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 3 4.162252 $955.6800 $229.6100
SENS -V5060 BEHIND EAR HEARING AID 3 4 10.644444 $2444.0600 $229.6100
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 6 10 14.277778 $6556.6500 $459.2200
SENS -V5264 EARMOLD 18 27 76.237820 $1382.1900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1190 1736 24195.526949 $1741110.3900 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 33 47 494.673810 $35596.7500 $71.9600
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 11.000000 $633.6000 $57.6000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 14.142857 $814.6300 $57.6000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 33 42 602.928570 $43386.7600 $71.9600
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 24.714286 $1778.4400 $71.9600
SPL -92508HA GROUP SPL SESSION PER CHILD 1 2 66.071429 $922.3600 $13.9600
TRAV -TRAVS Travel by mile 4084 9202 1219020.567102 $542464.1600 $0.4500
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Subtotal (Total Children Is Unduplicated) 21100 79681 1750191.003340 $20227578.2300 $11.5600
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Total 87080 1800392.789082 $21562686.6700 $11.9800
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Number of Children (Unduplicated) With at Least One Authorization 22776