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: 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 21910 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 249 253 368.742851 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 84 85 8368.833334 $309646.8400 $37.0000
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Subtotal (Total Children Is Unduplicated) 333 338 8737.576185 $309646.8400 $35.4400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 100 109 102.438887 $4968.2800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 13 13 13.044444 $736.8800 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 2.000000 $39.4200 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 90 90 87.724810 $2060.6600 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 13 13 5.822222 $80.7500 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 21 21 11.977779 $283.8800 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 4.294444 $38.9900 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 9 9 3.988888 $111.0100 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 13 13 12.894444 $1093.9600 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 2.000000 $102.1400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 15 15 11.433333 $190.9400 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 22 22 22.453968 $502.9700 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 14 8.805555 $396.2500 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 11 11 4.059436 $466.8200 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 21 24 33.173896 $1658.7000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 9 18.000000 $900.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 251 254 447.769113 $22388.4600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 4 5 8.000000 $600.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 29 29 52.664384 $3949.8300 $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 6 6 17.000000 $1275.0000 $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 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 10 10 16.361643 $1227.1300 $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 43 46 84.084932 $4666.7100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 14 14 26.356164 $1462.7700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 335 336 642.605020 $48195.3900 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 318 319 622.159295 $46661.9500 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 129 130 259.000000 $19425.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 85 85 169.000000 $12675.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 32 32 61.000000 $4575.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 137 138 254.031506 $19052.3600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 558 563 1022.993467 $56776.1700 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 171 171 330.151076 $18323.3900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 254 263 451.024455 $33826.8700 $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 2.900000 $145.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 2 3 8.928571 $446.4300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 50 52 29.903513 $1526.5800 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 7 7 4.850000 $247.5900 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.477778 $24.3900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 54 59 47.475341 $2423.6100 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.500000 $25.5300 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 232 245 168.722351 $8613.2700 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.005556 $0.2900 $51.4600
PSTF -97164 PT RE-EVAL EST PLAN CARE 35 36 10.805102 $551.6200 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.177778 $9.0800 $51.0600
PSTH -97162 PT EVAL MODERATE COMPLEXITY 38 39 27.288583 $1393.0800 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 149 163 103.777437 $5297.8300 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.127778 $6.5200 $51.0600
SCREEN-T1023 SCREENING 32 34 33.766667 $1688.3400 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 6.122222 $312.5400 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 11 11 8.900000 $454.3400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 265 288 162.724988 $8307.1400 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 2.116667 $108.0600 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.216667 $11.0600 $51.0600
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 7.481431 $381.9300 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 30 32 30.780159 $1571.3300 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 36 38 31.493628 $1403.0400 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
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Subtotal (Total Children Is Unduplicated) 2267 3871 5607.360857 $351776.7100 $62.7300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 73 78 78.249632 $391249.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 8 8 4.855556 $242.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 17 18 16.716665 $835.8300 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.833333 $131.2800 $71.6100
AUD -92633 AUD REHAB POSTLING HEARING LOSS 21 21 51.883594 $3715.3900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 30 31 33.316667 $7662.8400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 571 700 628.088054 $31404.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 73 93 65.273894 $3263.7000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 162 199 162.449958 $4061.2800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1030 1116 1855.744827 $92787.1900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 54 61 91.364283 $4568.2100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 135 142 124.446040 $3111.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 807 900 1256.132521 $62806.5500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 79 80 100.903567 $5045.1600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 58 98 90.642065 $2266.0600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 377 419 598.274996 $29913.7600 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 47 47 68.081350 $3404.0800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 47 56.526186 $1413.1500 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1096 1140 1489.610709 $74480.5100 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 94 96 105.600795 $5280.0500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 133 138 137.174209 $3429.3600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 107 126 693.142859 $17328.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4047 4423 29282.309467 $1464115.8600 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 413 438 2350.865841 $117543.2600 $50.0000
INTR -T1013 INTERPRETER 160 186 684.803097 $34240.1500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2491 3207 18685.701709 $186857.0500 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 551 610 3509.942821 $250750.4000 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 29 30 131.765078 $9413.3000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 107 117 739.783326 $42315.6300 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 6 15.357142 $878.4300 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 6 6 14.028570 $1002.2000 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 51 53 269.842061 $19277.5300 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 461 513 2905.906720 $207598.1300 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 20 24 103.790478 $7414.7800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 40 42 331.285713 $18936.3000 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 12.428571 $710.4200 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 12 12 15.305555 $1093.4300 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 46 53 198.247619 $14162.8400 $71.4400
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 2.533333 $577.5900 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 1.000000 $228.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 6 7 7.077778 $3227.4800 $456.0000
SENS -V5264 EARMOLD 18 19 14.077777 $253.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 839 915 5276.785657 $376973.7900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 22 25 145.676188 $10407.1200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 6 20.320635 $1162.3500 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 16 16 97.184129 $6942.8300 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 83 89 465.442852 $33251.2600 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 31 33 215.561108 $2991.9900 $13.8800
TRAV -TRAVS Travel by mile 878 1307 65826.810989 $29292.9300 $0.4400
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Subtotal (Total Children Is Unduplicated) 5946 17701 139034.145974 $3590018.8400 $25.8200
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Total 21910 153379.083016 $4251442.3800 $27.7200
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Number of Children (Unduplicated) With at Least One Authorization 6756