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
Eligibility Filter: Program Patients
With the filters selected there were 17778 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 321 331 494.911110 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 30 31 545.715874 $20191.4900 $37.0000
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Subtotal (Total Children Is Unduplicated) 352 363 1042.593651 $20264.2600 $19.4400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 119 128 98.378213 $4771.3400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 7.000000 $395.4300 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.044444 $20.5900 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 226 227 233.903173 $5494.3800 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 3.722222 $51.6300 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 7 7 5.394444 $127.8500 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 3.735921 $33.9200 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $9.9600 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 2.722222 $75.7600 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 1.044444 $40.1800 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 6 6 6.835921 $579.9600 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 1.013699 $51.7700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 5 5 4.044444 $67.5400 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 13.615873 $304.9900 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 9.671385 $435.2100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.376484 $43.3000 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 28 31 32.885616 $1644.2800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 426 433 782.034629 $39101.7200 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 11 11 19.005556 $1425.4200 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 6 6 10.005479 $750.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.500000 $412.5000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 3.000000 $225.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 2 2 3.000000 $225.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $300.0000 $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 51 51 84.823211 $4707.6900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 9 9 6.588737 $365.6700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 47 47 94.000000 $7050.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 40 40 78.000000 $5850.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 30 30 58.500000 $4387.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1050.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 12.505479 $937.9100 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 35 35 65.002740 $4875.2000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 99 101 180.834245 $10036.3000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 31 31 59.002740 $3274.6500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 42 46 90.076712 $6755.7500 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 1.571429 $78.5700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 5 5 12.499207 $638.0800 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 11 11 8.432877 $430.5000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 49 50 30.199945 $1541.7000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 4 4 4.916667 $251.0000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.397793 $71.3600 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 32 34 25.334922 $1293.3500 $51.0500
SCREEN-T1023 SCREENING 3 3 2.233333 $111.6700 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.210959 $3.1700 $15.0000
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 2.000000 $102.1000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 57 57 34.001295 $1735.7700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 11 11 10.766667 $549.6400 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 13 13 18.677777 $832.0900 $44.5500
VISF -92499 VISION EVALUATION FUNCTIONAL 1 1 0.300000 $15.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 1206 1513 2162.810904 $114432.8200 $52.9100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 37 43 41.566211 $207831.0000 $5000.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 11 11 7.102588 $355.1300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.377778 $27.0500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 5 5 3.383333 $778.1600 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 830 1044 989.636313 $49481.9000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 63 73 48.180655 $2409.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 175 205 118.931280 $2973.3400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1463 1603 2571.865038 $128593.2800 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 51 54 46.914288 $2345.7300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 164 173 172.502379 $4312.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1053 1187 1498.963484 $74948.1600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 57 57 59.888888 $2994.4400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 72 105 118.961911 $2974.0700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 615 654 787.485728 $39374.3400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 48 48 52.027779 $2601.4000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 29 48 53.670833 $1341.7700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1762 1831 2138.984117 $106949.1900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 76 78 93.667459 $4683.3700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 154 162 149.865872 $3746.6400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 6 6 11.642858 $291.0700 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 2.272222 $113.6100 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1148 1226 7480.544449 $374027.2600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 99 103 537.976192 $26898.8100 $50.0000
INTR -T1013 INTERPRETER 179 213 535.219635 $26761.0100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3305 4556 22810.568304 $228105.6800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 129 135 812.465075 $58042.5600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 28.642858 $2046.2400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 30 32 189.428572 $10835.3100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 5.571429 $318.6800 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 3 4 4.923810 $351.7600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.285714 $20.4100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 135 142 716.250794 $51168.9600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 7.428571 $530.7000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 6 6 39.357143 $2249.6600 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 9.142857 $653.1700 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 4.305556 $307.5900 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.210959 $13.7200 $65.0100
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.210959 $24.0500 $114.0200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 2.177778 $993.0800 $456.0000
SENS -V5264 EARMOLD 4 4 3.555556 $64.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 266 281 1617.446038 $115550.3100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 14 14 58.398413 $4172.0000 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 16.142857 $923.3700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 2.285714 $163.2900 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 22.438096 $1602.9800 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 13 15 155.999999 $2165.2800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 19 20 38.609525 $1428.5600 $37.0000
TRAV -TRAVS Travel by mile 1061 1735 95750.421680 $42608.9400 $0.4500
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Subtotal (Total Children Is Unduplicated) 6112 15902 139819.899547 $1591608.6000 $11.3800
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Total 17778 143025.304102 $1726305.6700 $12.0700
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Number of Children (Unduplicated) With at Least One Authorization 6915