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: 01-01-21 and 03-31-21 Date of Report: 05-04-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 22603 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 228 241 740.657939 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 50 52 2902.739681 $107401.3700 $37.0000
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Subtotal (Total Children Is Unduplicated) 276 293 3643.397620 $107401.3700 $29.4800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 87 99 79.646359 $3862.8600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 3.565068 $201.3900 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $19.7100 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 236 237 251.311111 $5903.3000 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 13 13 8.438889 $117.0500 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 36 36 19.948403 $472.7800 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 6.477778 $58.8200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 17 17 14.988889 $417.1400 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 3.000000 $115.4100 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 13 14.355555 $1217.9200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 4 4 3.311111 $169.1000 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 21 20.155556 $336.6000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 19 19 18.952359 $424.5300 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 4.334246 $195.0400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 2.906698 $334.2700 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 20 22 18.560808 $928.0500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 293 294 483.270030 $24163.4900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 35 65.249923 $4893.7400 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 13 13 19.019330 $1426.4500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 3 3 3.011111 $225.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 9 9 17.000000 $1275.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 21 23 40.656165 $3049.2200 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 2 2 2.005479 $150.4100 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 60 63 106.194358 $5893.7900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 5 5 9.000000 $499.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 315 315 606.318588 $45473.9000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 287 288 548.065749 $41104.9400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 155 155 306.066667 $22955.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 72 73 146.000000 $10950.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 32 32 62.500000 $4687.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 128 129 226.068488 $16955.1500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 471 472 872.249047 $48409.8300 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 105 105 199.030135 $11046.1800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 219 228 408.863792 $30664.7900 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 6 7 12.000000 $900.0000 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 3 3 4.833333 $241.6700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 43 43 12.361115 $631.0500 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 6 7 4.155555 $212.1400 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 7 7 6.016667 $307.1500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 37 37 38.276072 $1953.9900 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 0.205555 $10.4900 $51.0400
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 0.298630 $15.2500 $51.0600
OCTH -97167 OT EVAL HIGH COMPLEXITY 287 303 179.475892 $9162.2200 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.3000 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 0.483334 $24.6800 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 26 27 6.588888 $336.3600 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 6 6 3.816666 $194.8400 $51.0500
PSTF -97164TLGT PT RE-EVAL EST PLAN CARE 2 2 0.177701 $9.0700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 22 22 13.592236 $693.8800 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.233333 $11.9100 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 177 188 107.957249 $5511.2100 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.120548 $6.1500 $51.0300
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.177778 $9.0800 $51.0600
SCREEN-T1023 SCREENING 26 26 23.111111 $1155.5600 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.366667 $5.5000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 5.011111 $255.8200 $51.0500
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 5.719407 $291.9800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 284 302 147.898936 $7550.2400 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 5.499999 $280.7700 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 14 14 6.471308 $330.3600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 40 41 41.000000 $2093.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 36 36 38.579125 $1718.6900 $44.5500
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Subtotal (Total Children Is Unduplicated) 2416 3872 5279.288797 $323984.3300 $61.3700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 86 98 91.448022 $457241.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 3 3 3.600001 $180.0100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 15 15 10.933333 $546.6700 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $71.6100 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 17 17 23.134921 $1656.6900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 18 18 13.250457 $3047.5900 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 650 832 753.377035 $37668.9900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 44 47 26.500737 $1325.0500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 179 225 205.719810 $5143.0100 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1135 1230 1779.234535 $88961.6300 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 35 37 44.099207 $2204.9600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 119 123 124.161903 $3104.0500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 785 893 1011.555981 $50577.8100 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 42 42 65.802379 $3290.1100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 54 88 102.299998 $2557.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 458 501 686.237285 $34311.7900 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 30 30 31.031746 $1551.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 42 55.133333 $1378.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1187 1235 1382.740469 $69136.9900 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 52 53 55.394447 $2769.7400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 122 128 138.169046 $3454.2200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 1.000000 $73.3200 $73.3200
DSTT -DSTT DIRECT SERVICE COORDINATOR TRAVEL 1 1 1.933333 $0.0000 $0.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 137 154 1341.250004 $33531.2400 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 2 2 6.523810 $326.1900 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4295 4653 27876.814444 $1393840.1200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 281 298 1599.590480 $79979.4800 $50.0000
INTR -T1013 INTERPRETER 208 253 720.187546 $36009.3800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2365 3223 16290.392170 $162903.8600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 690 744 3729.827786 $266458.8800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 25 25 121.009526 $8644.9000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 135 146 745.889678 $42664.8800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 4 4 25.642857 $1466.7700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 5 5 20.499999 $1464.5200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 33 35 161.288889 $11522.4800 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 651 686 3441.585326 $245866.7700 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 26 27 130.730160 $9339.3500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 44 48 240.200001 $13729.8100 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 3 11.071429 $632.8400 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 6 6 17.128571 $1223.6700 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 24 24 125.723809 $8981.7000 $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 3 3 3.328615 $758.9200 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 2 2 1.054795 $240.4900 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 2 2 1.144444 $521.8500 $455.9800
SENS -V5264 EARMOLD 18 19 12.766971 $229.8100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 990 1053 5821.667486 $415899.8500 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 27 27 107.885716 $7707.3500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 12.571429 $719.0800 $57.2000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 6.000000 $343.2000 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 17 18 129.114287 $9223.9300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 25 27 166.304764 $11880.8100 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 36 37 195.183333 $2709.1500 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 11.714286 $162.5900 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 4 5 5.107937 $188.9900 $37.0000
TRAV -TRAVS Travel by mile 758 1245 64702.009286 $28792.3900 $0.4500
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Subtotal (Total Children Is Unduplicated) 6308 18438 134389.967812 $3568282.8900 $26.5500
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Total 22603 143312.654229 $3999668.5900 $27.9100
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Number of Children (Unduplicated) With at Least One Authorization 7383