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: 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 22157 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 3 3 3.311112 $122.5100 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 225 228 994.321429 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 54 55 5391.698414 $199492.8500 $37.0000
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Subtotal (Total Children Is Unduplicated) 282 286 6389.330955 $199615.3600 $31.2400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 90 100 78.496269 $3807.0800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 10 7.241248 $409.0600 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 105 105 121.577321 $2855.8500 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 5 5 3.511111 $48.7000 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 32 32 14.735692 $349.2300 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 4.988888 $45.3000 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 13 13 7.038888 $195.8900 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 12 12 14.616667 $1240.0800 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 3 3 3.000000 $153.2100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 18 18 12.138888 $202.7200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 12 12 12.377778 $277.2600 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 12 6.896650 $310.3500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.616438 $70.9000 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 15 18 20.244293 $1012.2200 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 3 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 278 279 462.684705 $23134.2100 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 33 33 62.505479 $4687.9100 $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 5 5 7.571429 $567.8600 $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 4 4 7.000000 $525.0000 $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 52 56 91.320625 $5068.3000 $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 289 290 552.065749 $41404.9400 $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 129 130 228.068488 $17105.1500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 472 473 870.765484 $48327.5000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 108 108 205.030135 $11379.1800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 221 230 406.380229 $30478.5200 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 6 7 12.000000 $900.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 1.400000 $70.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 3 3 13.023810 $651.1900 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 42 42 14.411113 $735.7000 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 3 3 2.388889 $121.9500 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 12.342857 $630.1100 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 43 45 28.738282 $1467.1000 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.087671 $4.4800 $51.0700
OCTH -97167 OT EVAL HIGH COMPLEXITY 272 285 181.587535 $9270.0800 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 2 2 1.322222 $67.5000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 22 24 6.794444 $346.8500 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 3 2.388889 $121.9500 $51.0500
PSTF -97164TLGT PT RE-EVAL EST PLAN CARE 2 2 0.177701 $9.0700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.383333 $121.6700 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 25 26 16.401981 $837.3300 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.050000 $2.5500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 138 152 85.849341 $4382.6400 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.038889 $1.9900 $51.0600
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.322222 $16.4500 $51.0500
SCREEN-T1023 SCREENING 27 27 26.844444 $1342.2200 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 2.633333 $39.5000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 3.000000 $153.1500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 6.271614 $320.1700 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 294 310 161.754938 $8257.6200 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.038889 $104.0900 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 0.555556 $28.3600 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 16 16 17.383169 $887.4100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 28 30 29.600000 $1511.0800 $51.0500
SPCH -92524TLGT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 0.400000 $20.4200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 34 36 28.026190 $1248.5700 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.115068 $5.1300 $44.5600
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.611111 $27.2200 $44.5500
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Subtotal (Total Children Is Unduplicated) 2168 3646 5082.565507 $318512.5900 $62.6700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 76 87 93.757783 $468789.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 0.222222 $11.1100 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 8 8 8.800000 $440.0000 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 22 22 39.447543 $2824.8400 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 26 26 23.437301 $5390.5800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 670 852 772.373461 $38618.7900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 46 49 31.956292 $1597.8300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 180 224 170.624572 $4265.6300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1075 1163 1885.255144 $94262.7100 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 47 49 68.636508 $3431.8200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 140 143 152.088886 $3802.2200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 865 972 1322.252941 $66112.5700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 49 49 47.261111 $2363.0600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 73 119 116.433333 $2910.8300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 366 403 566.718257 $28335.9300 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 36 36 50.253965 $2512.6900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 31 55 37.122216 $928.0400 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1195 1238 1618.821826 $80941.1100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 63 64 72.326984 $3616.3500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 150 156 162.504759 $4062.6100 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 121 140 1350.142846 $33753.5900 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 2.333333 $116.6700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4268 4624 28951.946452 $1447597.6300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 301 323 1591.935693 $79596.7900 $50.0000
INTR -T1013 INTERPRETER 202 251 898.486750 $44924.3400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2549 3323 17757.691005 $177576.9600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 639 682 3746.429324 $267645.0500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 21 21 104.023808 $7431.4500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 110 116 786.887957 $45009.9900 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 28.642857 $1638.3700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 6 6 37.865078 $2705.0800 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 36 38 143.944442 $10283.3900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 505 536 3059.681714 $218583.8000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 20 21 146.442856 $10461.8800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 40 45 299.285714 $17107.1600 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 6 6 32.090475 $2292.5500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 37 39 156.664282 $11192.0800 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.011111 $65.7200 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.888889 $202.6700 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 2.455555 $1119.7100 $455.9900
SENS -V5264 EARMOLD 12 12 10.022222 $180.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 846 904 5333.306809 $381011.6800 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 27 29 160.219047 $11446.0600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 11.500000 $657.8000 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 14 14 76.542857 $5468.2200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 33 33 183.938093 $13140.5500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 33 33 186.209780 $2584.6000 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 2 3 0.642858 $23.7800 $37.0000
TRAV -TRAVS Travel by mile 846 1294 66767.490588 $29711.5300 $0.4400
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Subtotal (Total Children Is Unduplicated) 6045 18225 139071.017499 $3639203.6600 $26.1700
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Total 22157 150542.913961 $4157331.6200 $27.6200
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Number of Children (Unduplicated) With at Least One Authorization 6682