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
Eligibility Filter: Program Patients
With the filters selected there were 29595 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 289 291 824.603962 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 2.571429 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 66 66 2179.451986 $80639.7300 $37.0000
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Subtotal (Total Children Is Unduplicated) 357 359 3008.594044 $80712.5000 $26.8300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 142 155 140.331324 $6806.0700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 15 16 13.150380 $742.8600 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 7 7 7.000000 $137.9700 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 168 169 178.865080 $4201.5400 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 31 31 27.294445 $378.5700 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 42 42 35.911108 $851.0900 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 31 31 18.993912 $172.4700 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 39 39 29.155556 $811.4000 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 12 12 15.833333 $609.1100 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 39 39 56.487563 $4792.4100 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 14 14 16.520102 $843.6900 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 48 48 45.401588 $758.2100 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 26 26 24.693911 $553.1400 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 24 24 18.986150 $854.3900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 7 3.782038 $434.9300 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 36 39 39.044596 $1952.2300 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 5.000000 $250.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 415 422 760.599022 $38029.9400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 56 56 117.600794 $8820.0700 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 17 17 29.016590 $2176.2500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 9.500000 $712.5000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 9 9 15.005479 $1125.4100 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 9 9 14.005479 $1050.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 38 51 91.557534 $6866.8200 $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 96 101 172.321005 $9563.8300 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 14 14 16.027549 $889.5300 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 370 370 704.527395 $52839.5600 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 359 361 710.172753 $53262.9600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 183 183 355.500000 $26662.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 116 118 233.005479 $17475.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 41 41 69.008219 $5175.6200 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 152 153 285.164383 $21387.3200 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 601 610 1106.486683 $61410.0400 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 127 129 241.021917 $13376.7200 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 341 378 677.724521 $50829.3800 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 14 14 27.000000 $2025.0000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 1.571429 $78.5700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 3 4.400000 $220.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 60 61 19.801814 $1010.8700 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 7 7 2.405555 $122.8000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 3.033334 $154.8600 $51.0500
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.488889 $24.9600 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 46 51 63.754371 $3254.6600 $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 339 356 230.882574 $11786.5800 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 1.950000 $99.5500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 37 38 12.649697 $645.7700 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 5 6 2.355556 $120.2500 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 4.000000 $204.2000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 33 35 23.254643 $1187.1500 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.155556 $7.9400 $51.0600
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.057534 $2.9400 $51.0200
PSTH -97163 PT EVAL HIGH COMPLEXITY 190 206 135.826801 $6933.9700 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 3 3 0.235769 $12.0400 $51.0600
SCREEN-T1023 SCREENING 39 41 41.000000 $2050.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.216438 $18.2500 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 10 10 8.516667 $434.7800 $51.0500
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 15 15 16.961111 $865.8600 $51.0500
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 1.411111 $72.0400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 467 500 275.427245 $14060.5700 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 20 20 9.883333 $504.5400 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 17 17 10.324050 $527.0400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 32 32 28.916666 $1476.1900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 46 47 42.714863 $1902.9500 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 2.511720 $111.9000 $44.5500
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Subtotal (Total Children Is Unduplicated) 3107 5229 7277.577956 $448085.7900 $61.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 139 159 157.478876 $787395.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 8 9 48.773013 $2438.6400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 24 24 24.065906 $1203.3000 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 10 10 14.435714 $1033.7400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 40 40 59.499566 $13684.9300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 910 1170 1174.355812 $58717.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 66 76 67.261608 $3363.1000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 306 379 307.628413 $7690.7600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1333 1434 2572.148214 $128607.4100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 76 78 94.079370 $4703.9900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 153 159 156.616665 $3915.4100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1095 1189 1675.572062 $83778.6100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 75 77 109.958725 $5497.9200 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 61 85 81.116667 $2027.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 524 563 872.647861 $43632.4200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 49 49 56.685712 $2834.2800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 32 51 56.404169 $1410.1100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1647 1706 2324.287513 $116214.3400 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 81 84 100.973015 $5048.6500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 155 160 152.053961 $3801.3300 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 123 138 1407.928563 $35198.2300 $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 5259 5651 38563.571199 $1928179.4700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 356 368 2066.834828 $103341.8300 $50.0000
INTR -T1013 INTERPRETER 193 234 719.914870 $35995.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3230 4287 24337.779076 $243377.9400 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 872 934 5665.211739 $404722.8200 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 40 41 199.084920 $14222.6500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 142 145 911.057144 $52112.4700 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 7 7 30.499999 $1744.6100 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 8 8 67.942857 $4853.8300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 44 47 250.492058 $17895.1700 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 754 806 5011.005532 $357986.3800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 36 40 194.301587 $13880.9000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 59 61 366.631748 $20956.6700 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 6 6 46.285713 $2645.7000 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 6 6 40.971429 $2927.0000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 44 45 253.414283 $18103.9100 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 7 7 3.515069 $228.4800 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.202740 $23.1100 $113.9800
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.188889 $43.0700 $228.0100
SENS -V5060 BEHIND EAR HEARING AID 3 4 3.394521 $773.9500 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 8 8 9.033333 $4119.1800 $456.0000
SENS -V5264 EARMOLD 27 28 49.452664 $890.1500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1608 1728 10947.032648 $782056.3200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 71 71 384.958377 $27501.4600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 6 6 32.714286 $1871.2600 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 17 18 103.714285 $7409.3500 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 57 57 389.641268 $27836.0000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 68 69 458.211903 $6359.9900 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 1.000000 $37.0000 $37.0000
TRAV -TRAVS Travel by mile 1112 1679 85860.170000 $38207.7800 $0.4500
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Subtotal (Total Children Is Unduplicated) 8115 24007 188485.600370 $5432717.0900 $28.8200
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Total 29595 198771.772370 $5961515.3800 $29.9900
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Number of Children (Unduplicated) With at Least One Authorization 9091