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: 10-01-20 and 12-31-20 Date of Report: 01-23-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 21895 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 1.966667 $72.7700 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 241 251 322.319043 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 86 87 3180.520638 $117679.2700 $37.0000
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Subtotal (Total Children Is Unduplicated) 325 339 3504.806348 $117752.0400 $33.6000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 89 96 73.582246 $3568.7400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 10.072222 $568.9800 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 2.000000 $39.4200 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 243 245 254.892062 $5987.4100 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 8 8 4.250000 $58.9500 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 24 25 10.816667 $256.3600 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 5.205555 $47.2700 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 8 8 6.138888 $170.8400 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 18 19 17.438890 $1479.5200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 2.033333 $103.8400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 14.272222 $238.3500 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 7 5.900000 $132.1600 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 6.283257 $282.7500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 2.512329 $288.9100 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 25 28 28.874505 $1443.7300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 313 316 571.444826 $28572.2300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 35 65.500000 $4912.5000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 11 11 19.005479 $1425.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 4 4 6.500000 $487.5000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 6 6 9.005479 $675.4100 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 7 7 11.005479 $825.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 30 43 76.557534 $5741.8200 $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 67 71 117.165068 $6502.6600 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 10 10 13.010959 $722.1000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 256 256 482.117806 $36158.8400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 259 260 512.074123 $38405.5700 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 116 116 223.487671 $16761.5800 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 79 81 159.005479 $11925.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 25 25 43.002740 $3225.2000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 96 97 186.054794 $13954.1100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 404 410 735.173965 $40802.1800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 85 87 164.019177 $9103.0700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 225 247 435.126480 $32634.5200 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 10 10 19.000000 $1425.0000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 1.571429 $78.5700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 5 15.604763 $780.2400 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 38 41 10.117442 $516.5100 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 4 4 0.844977 $43.1300 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 3 3 1.472223 $75.1600 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.022222 $1.1300 $51.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 33 33 30.501989 $1557.1200 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 4 4 3.483333 $177.8200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 249 256 156.390552 $7983.7400 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 0.783333 $39.9900 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.316667 $16.1700 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 24 24 7.100772 $362.5000 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 2 2 4.000000 $204.2000 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 17 17 11.003730 $561.7400 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 0.194444 $9.9200 $51.0400
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 2 2 0.288889 $14.7500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 180 191 109.539203 $5591.9700 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 3 3 0.594444 $30.3400 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.316667 $16.1700 $51.0600
SCREEN-T1023 SCREENING 56 58 57.844445 $2892.2300 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 8.000000 $408.4000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 16 16 22.405555 $1143.8000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 297 309 177.732835 $9073.2700 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 6.509207 $332.2900 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.438889 $22.4100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 8 9 7.125396 $363.7500 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 30 31 27.255555 $1391.3900 $51.0500
SPCH -92524TLGT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.327778 $16.7300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 53 53 57.058708 $2541.9700 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.100000 $4.4600 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.300000 $15.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 2368 3686 5034.774682 $306576.3800 $60.8900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 86 94 88.857708 $444288.0000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 7.477778 $373.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 11 11 5.861111 $293.0600 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 2 2 5.285714 $378.5100 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 8 8 9.333333 $668.3600 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 13 14 16.655555 $3830.7700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 620 777 739.215886 $36960.8600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 39 45 31.209954 $1560.5100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 201 261 206.333084 $5158.3700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1053 1155 1846.665835 $92333.3200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 37 40 37.680955 $1884.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 127 135 137.402375 $3435.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 694 778 971.099200 $48554.9500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 40 40 42.446032 $2122.3000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 54 79 90.438099 $2260.9700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 458 483 550.588115 $27529.5000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 37 37 40.685717 $2034.3000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 35 35.500001 $887.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1174 1219 1376.428574 $68821.4600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 51 52 52.289680 $2614.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 120 127 122.836505 $3070.9100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 119 130 1131.857144 $28296.4200 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 2.272222 $113.6100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4152 4424 27553.019119 $1377650.7900 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 298 309 1555.712629 $77785.6600 $50.0000
INTR -T1013 INTERPRETER 179 213 530.505349 $26525.2900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2343 3191 15905.916682 $159059.1700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 601 646 3513.200801 $250983.0200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 35 36 149.988886 $10715.2100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 177 184 1041.797620 $59590.8300 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 7 7 29.878572 $1709.0500 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 4 4 20.571428 $1469.6300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 29 30 106.983333 $7642.8900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 659 683 3512.951736 $250965.2800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 30 32 135.332541 $9668.1500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 39 44 267.659525 $15299.4000 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 19.500000 $1114.6200 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 6 6 30.752381 $2196.9600 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 22 23 96.380952 $6885.4500 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 1.000000 $65.0000 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 4 4 1.140183 $259.9400 $227.9800
SENS -V5060 BEHIND EAR HEARING AID 2 2 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 0.788889 $359.7400 $456.0100
SENS -V5264 EARMOLD 16 16 11.004566 $198.0800 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1001 1063 6416.070659 $458364.1800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 49 51 242.133331 $17298.0100 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 6 32.500000 $1859.0000 $57.2000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 2 2 12.000000 $686.4000 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 17 17 121.571429 $8685.0700 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 33 34 189.749208 $13555.6900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 54 57 351.361904 $4876.9000 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 12.714286 $176.4700 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 12 13 19.500001 $721.5000 $37.0000
TRAV -TRAVS Travel by mile 765 1232 66200.588337 $29459.2700 $0.4500
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Subtotal (Total Children Is Unduplicated) 6232 17870 135632.694924 $3573753.7400 $26.3500
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Total 21895 144172.275954 $3998082.1600 $27.7300
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Number of Children (Unduplicated) With at Least One Authorization 7326