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: 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 19841 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 209 209 727.736499 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 49 49 1879.960321 $69558.5400 $37.0000
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Subtotal (Total Children Is Unduplicated) 259 259 2609.663487 $69631.3100 $26.6800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 94 102 96.342737 $4672.6200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 14 11.150380 $629.8800 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.544444 $30.4400 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 108 109 115.165079 $2705.2300 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 13 13 6.500001 $90.1600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 21 21 13.711109 $324.9500 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 5.927778 $53.8200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 6.927778 $192.8000 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 1.544444 $59.4100 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 15 15 15.238888 $1292.8600 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 6 6 6.281746 $320.8100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 25 25 25.662698 $428.5700 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 11 11 8.416666 $188.5300 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 12 10.369863 $466.6500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 1.291019 $148.4700 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 27 29 28.563622 $1428.1800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 5.000000 $250.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 309 313 561.397358 $28069.8600 $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 30 30 57.500000 $4312.5000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 10 10 17.005479 $1275.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 5.500000 $412.5000 $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 5 5 8.005479 $600.4100 $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 29 42 74.557534 $5591.8200 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 59 62 101.973060 $5659.5100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 9 9 12.010959 $666.6000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 254 254 480.027395 $36002.0600 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 261 262 518.065904 $38854.9500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 116 116 225.000000 $16875.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 81 83 163.005479 $12225.4100 $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 97 98 188.054794 $14104.1100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 403 409 737.023280 $40904.8200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 83 85 160.019177 $8881.0700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 226 248 441.409454 $33105.7400 $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 1 2 2.900000 $145.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 41 42 10.594139 $540.8200 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 7 7 2.405555 $122.8000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 7 7 2.033334 $103.8100 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.488889 $24.9600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 23 23 34.885411 $1780.9000 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.175342 $8.9500 $51.0400
OCTH -97167 OT EVAL HIGH COMPLEXITY 222 228 151.112917 $7714.3200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 29 30 10.244141 $522.9700 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 4 5 2.350000 $119.9700 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 20 21 13.443000 $686.2700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 121 127 73.450035 $3749.6500 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 3 3 0.235769 $12.0400 $51.0600
SCREEN-T1023 SCREENING 24 26 26.000000 $1300.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.316667 $118.2700 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 7 7 11.216667 $572.6100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 253 263 142.425906 $7270.8400 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 6.583333 $336.0800 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 6.738889 $344.0200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 24 24 21.449999 $1095.0200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 25 26 27.253752 $1214.1600 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 2.355556 $104.9400 $44.5500
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Subtotal (Total Children Is Unduplicated) 2037 3340 4746.432553 $294972.9700 $62.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 82 89 92.136944 $460685.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 4.866666 $243.3300 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 10 10 10.200001 $510.0100 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 9 9 13.435714 $962.1300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 15 15 20.555556 $4727.7900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 616 795 786.178766 $39309.0500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 40 46 39.498050 $1974.9100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 190 233 192.802412 $4820.0900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 927 998 1710.606312 $85530.3200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 48 50 57.502384 $2875.1300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 115 119 122.555554 $3063.8900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 723 785 1047.398018 $52369.9200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 51 53 78.863487 $3943.1500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 46 65 65.305555 $1632.6400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 363 393 608.349212 $30417.5000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 39 39 49.307934 $2465.3900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 33 42.516669 $1062.9200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1088 1128 1445.364904 $72268.2500 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 49 50 56.087302 $2804.3700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 120 125 122.026186 $3050.6500 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 88 101 975.999993 $24400.0100 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 1.400000 $70.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3781 4044 27888.503834 $1394425.8100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 268 278 1548.177688 $77408.9400 $50.0000
INTR -T1013 INTERPRETER 172 211 640.914870 $32045.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2298 3026 17303.487862 $173034.9700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 543 580 3446.969826 $246251.6200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 28 29 142.289682 $10165.1800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 97 98 605.999998 $34663.2100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 6 6 22.785713 $1303.3500 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 4 4 44.314286 $3165.8100 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 32 35 164.463489 $11749.2900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 471 501 3118.312284 $222772.3000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 24 27 129.311112 $9237.9800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 41 43 280.000002 $16004.8000 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 17.714285 $1012.5600 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 3 3 16.971429 $1212.4400 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 31 32 173.652379 $12405.7300 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 4 4 2.320548 $150.8400 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.188889 $43.0700 $228.0100
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.394521 $317.9500 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 2.000000 $912.0000 $456.0000
SENS -V5264 EARMOLD 11 11 14.766667 $265.8000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 800 845 5332.528542 $380955.9700 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 34 34 215.138095 $15369.4600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 26.142857 $1495.3700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 11 12 81.285713 $5807.0600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 35 35 244.069841 $17436.3700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 37 38 263.330952 $3655.0400 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 784 1192 64513.880334 $28708.6800 $0.4500
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Subtotal (Total Children Is Unduplicated) 5485 16242 133785.873317 $3501274.5400 $26.1700
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Total 19841 141141.969357 $3865878.8200 $27.3900
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Number of Children (Unduplicated) With at Least One Authorization 6145