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
Eligibility Filter: Program Patients
With the filters selected there were 33642 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 314 319 1153.242855 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 86 87 6935.134922 $256600.0000 $37.0000
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Subtotal (Total Children Is Unduplicated) 403 409 8091.688889 $256722.5200 $31.7300
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 146 168 123.137897 $5972.1900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 14 11.241248 $635.0200 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 0.305556 $6.0200 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 164 164 179.504719 $4216.5700 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 18 19 18.333334 $254.2800 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 45 45 24.674581 $584.7900 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 29 30 26.151587 $237.4600 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 31 32 28.396031 $790.2600 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 4.000000 $153.8800 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 30 31 36.637302 $3108.3200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 8 8 9.000000 $459.6300 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 38 38 31.129364 $519.8600 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 31 31 38.692858 $866.7200 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 29 29 17.264229 $776.8900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 10 10 4.945434 $568.7400 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 22 26 29.955405 $1497.7800 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 3 4 8.000000 $400.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 409 410 691.097969 $34554.8700 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 48 48 90.816590 $6811.2500 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 19 19 29.019330 $2176.4500 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 11.571429 $867.8600 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 4 4 4.011111 $300.8300 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 5 5 7.005479 $525.4100 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 13 13 24.000000 $1800.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 33 35 65.156165 $4886.7200 $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 84 89 144.076789 $7996.2700 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 9 9 16.000000 $888.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 480 480 926.318588 $69473.9000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 412 413 790.571228 $59292.8600 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 231 231 458.566667 $34392.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 101 102 204.000000 $15300.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 48 48 103.357143 $7751.7800 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 198 199 354.584925 $26593.8900 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 702 704 1320.938087 $73312.0700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 149 149 283.041093 $15708.7900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 302 319 565.838546 $42437.9000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 11 12 22.000000 $1650.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 3.766667 $188.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 6 15.923810 $796.1900 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 62 63 18.944448 $967.1300 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 4 4 2.777778 $141.8100 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 13.687301 $698.7400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 61 65 43.197633 $2205.2500 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.087671 $4.4800 $51.0700
OCTH -97167 OT EVAL HIGH COMPLEXITY 450 472 313.375812 $15997.8400 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 3 3 1.549619 $79.1100 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 29 33 9.124733 $465.8200 $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 3 3 0.349923 $17.8600 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 6 6 4.672222 $238.5200 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 38 40 27.814680 $1419.9500 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 2 2 0.211644 $10.8000 $51.0400
PSTH -97163 PT EVAL HIGH COMPLEXITY 222 242 142.011275 $7249.6800 $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 2 2 1.322222 $67.5000 $51.0500
SCREEN-T1023 SCREENING 51 51 50.844444 $2542.2200 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 4 18.734115 $281.0100 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 6.527777 $333.2400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 11 11 8.616058 $439.8500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 546 588 335.862216 $17145.7500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 4.427778 $226.0400 $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 21 21 20.460947 $1044.5300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 50 52 64.722222 $3304.0700 $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 65 67 51.351684 $2287.7100 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.115068 $5.1300 $44.5600
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.611111 $71.7700 $44.5500
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Subtotal (Total Children Is Unduplicated) 3421 5728 7872.992577 $486434.0800 $61.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 128 142 139.226732 $696134.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 7 7 7.695237 $384.7600 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 28 31 87.420928 $4371.0500 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 26 26 43.758654 $3133.5500 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 50 51 47.200771 $10856.1800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1023 1335 1285.735820 $64286.9900 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 74 82 58.864436 $2943.2300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 288 353 273.364118 $6834.1300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1573 1707 2842.407920 $142120.3400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 76 78 112.051589 $5602.5800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 203 208 203.244443 $5081.1100 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1319 1484 1966.389332 $98319.3500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 67 69 70.911112 $3545.5600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 99 159 147.072226 $3676.8200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 539 593 840.888092 $42044.4000 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 49 49 72.972218 $3648.5900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 39 67 46.872216 $1171.7900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1865 1940 2502.450399 $125122.5700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 95 98 116.865875 $5843.3000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 222 230 220.599204 $5514.9700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 176 204 2223.552366 $55588.8300 $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 6032 6590 40465.196305 $2023260.2200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 391 416 2051.654732 $102582.7300 $50.0000
INTR -T1013 INTERPRETER 224 275 982.879607 $49143.9800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3581 4725 25079.210751 $250792.1800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1053 1141 6105.708664 $436192.0000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 32 32 160.873807 $11492.8200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 162 175 1144.757004 $65480.0900 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 9 9 70.785714 $4048.9400 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 7 7 39.665078 $2833.6700 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 43 45 191.649204 $13691.4300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 837 904 5145.958692 $367627.4500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 31 33 216.966664 $15500.0900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 51 57 346.178572 $19787.5500 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 15.500000 $885.9800 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 9 9 46.233332 $3302.9100 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 51 54 223.664280 $15978.5600 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.011111 $65.7200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.219178 $24.9900 $114.0100
SENS -V5050 IN EAR MONAURAL HEARING AID 6 6 6.438585 $1468.0000 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 4 5 3.755555 $856.2500 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 11 11 9.855403 $4494.0600 $456.0000
SENS -V5264 EARMOLD 37 38 38.953108 $701.1500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1820 1988 11603.387035 $828946.4400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 61 66 350.130952 $25013.3600 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 13.642857 $780.3700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 19 20 108.757142 $7769.6100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 56 57 309.938091 $22141.9900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 62 62 342.028828 $4747.3700 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 3 4 1.142858 $42.2800 $37.0000
TRAV -TRAVS Travel by mile 1191 1854 89152.341358 $39672.7900 $0.4400
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Subtotal (Total Children Is Unduplicated) 9098 27505 197540.361488 $5605665.7600 $28.3800
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Total 33642 213505.042954 $6348822.3600 $29.7400
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Number of Children (Unduplicated) With at Least One Authorization 10059