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: 04-01-21 and 06-30-21 Date of Report: 07-15-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 22765 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 249 256 289.724599 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 61 61 5587.389682 $206733.4200 $37.0000
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Subtotal (Total Children Is Unduplicated) 308 317 5877.114281 $206733.4200 $35.1800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 105 114 91.624048 $4443.7700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 11 11 9.421081 $532.2000 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 1.477778 $29.1300 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 187 188 197.103740 $4629.9700 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 12 12 9.016668 $125.0600 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 29 29 17.222223 $408.1700 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 13 13 9.150001 $83.0800 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 14 14 9.850001 $274.1300 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 1.477778 $56.8500 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 15 16 28.417461 $2410.9500 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 5 5 12.870635 $657.3100 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 22 22 35.894445 $599.4400 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 13 13 11.788890 $264.0700 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 16 9.945509 $447.5500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 7 7 3.802588 $437.3000 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 22 25 33.236910 $1661.8500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 7 11 21.000000 $1050.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 268 270 461.268723 $23063.4400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 5 6 10.000000 $750.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 28 28 52.500000 $3937.5000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 25 26 50.005479 $3750.4100 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 7 7 11.357143 $851.7800 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 1.000000 $75.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 8 8 14.005479 $1050.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 17 18 34.500000 $2587.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 46 49 90.084932 $4999.7100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 14 14 28.000000 $1554.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 334 335 640.605020 $48045.3900 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 323 324 632.159295 $47411.9500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 130 131 261.000000 $19575.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 87 87 173.000000 $12975.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 31 31 60.000000 $4500.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 138 139 258.026027 $19351.9400 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 555 560 1024.557851 $56862.9800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 169 169 328.145597 $18212.0800 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 250 259 448.445982 $33633.4700 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 5 5 10.000000 $750.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.133333 $6.6700 $49.9900
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 2 1.300000 $65.0000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 39 39 10.149772 $518.1500 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 5 5 1.194444 $60.9700 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 8.400000 $428.8200 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.005556 $0.2900 $51.4600
OCTH -97166 OT EVAL MODERATE COMPLEXITY 49 50 37.567362 $1917.8200 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 252 267 175.907501 $8980.0700 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 21 21 6.583107 $336.0800 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 3 3 0.794444 $40.5500 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 30 31 20.449544 $1043.9500 $51.0500
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 148 159 80.472767 $4108.1400 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 3 3 1.052359 $53.7200 $51.0500
SCREEN-T1023 SCREENING 32 34 34.000000 $1700.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.966667 $14.5000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 6 6 4.394444 $224.3300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 13 13 9.872222 $503.9800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 304 314 164.073062 $8375.9500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 5.277778 $269.4300 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.216667 $62.1100 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 12 12 16.179681 $825.9700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 44 45 47.485714 $2424.1500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 40 40 27.121387 $1208.2700 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 4 4 2.313470 $103.0600 $44.5500
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Subtotal (Total Children Is Unduplicated) 2486 4052 5759.872565 $356073.5200 $61.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 104 113 110.414350 $552071.5000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 6 6 6.233334 $311.6700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 13 13 12.911111 $645.5600 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 11 11 23.097619 $1654.0200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 21 21 30.200001 $6946.0200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 602 779 693.566627 $34678.4300 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 73 95 70.366751 $3518.3500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 160 195 157.333292 $3933.3600 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1053 1171 1775.559935 $88778.0400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 55 58 80.280951 $4014.0500 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 114 125 119.636514 $2990.9300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 818 927 1156.390828 $57819.5800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 61 67 79.926582 $3996.3100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 55 91 107.297617 $2682.4400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 371 403 498.032542 $24901.6400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 41 43 58.387697 $2919.3800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 20 33 44.515078 $1112.8800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1194 1252 1495.930378 $74796.5700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 76 81 82.920629 $4146.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 126 136 156.544448 $3913.6200 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 1 1 0.288889 $21.1800 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 143 172 1712.857147 $42821.4200 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 2.466667 $123.3400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4177 4525 27946.766368 $1397338.2400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 414 433 2451.831762 $122591.5100 $50.0000
INTR -T1013 INTERPRETER 170 193 756.165004 $37808.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2409 3264 16713.340154 $167133.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 672 717 3807.080179 $271977.7500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 22 24 124.930161 $8925.0100 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 125 133 888.925995 $50846.5800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 23.607143 $1350.3300 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 7 7 23.295237 $1664.2200 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 47 48 212.453971 $15177.7200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 600 641 3288.473040 $234928.4200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 26 31 118.204763 $8444.5400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 36 37 192.714288 $11015.5400 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 20.857143 $1192.1900 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 3 3 8.347619 $596.3500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 46 52 238.742861 $17055.7900 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 5 2.708523 $176.0500 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 2.922222 $666.2600 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 4.000000 $1824.0000 $456.0000
SENS -V5264 EARMOLD 17 17 15.555555 $280.0000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 950 1026 5483.573840 $391746.4100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 35 38 170.133336 $12154.3400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 8 18.534921 $1060.2000 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 14 14 98.000000 $7001.1200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 59 64 344.499999 $24611.1000 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 25 27 132.881213 $1844.3900 $13.8800
TRAV -TRAVS Travel by mile 819 1281 68238.661893 $30366.2100 $0.4500
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Subtotal (Total Children Is Unduplicated) 6240 18396 139803.366177 $3738800.2000 $26.7400
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Total 22765 151440.353023 $4301607.1400 $28.4000
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Number of Children (Unduplicated) With at Least One Authorization 7493