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: 07-01-21 and 09-30-21 Date of Report: 10-13-21 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 23167 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 257 268 2122.558738 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 64 65 5249.911109 $194246.7000 $37.0000
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Subtotal (Total Children Is Unduplicated) 320 333 7372.469847 $194246.7000 $26.3500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 96 101 88.238204 $4279.5500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 12 12 10.707763 $604.8800 $56.4900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 151 152 159.000000 $3734.9100 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 2.922222 $40.5300 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 25 25 12.263317 $290.6400 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 10 10 6.477778 $58.8200 $9.0800
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 7.477778 $208.1100 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $38.4700 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 15 15 19.255556 $1633.6500 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 5 5 5.000000 $255.3500 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 16 16 10.677778 $178.3200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 13 13 13.805556 $309.2500 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 12 9.069027 $408.1100 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 0.712329 $81.9300 $115.0100
EVAL -96111 DEVELOPMENTAL EVALUATION 27 31 43.879300 $2193.9700 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 177 179 307.399981 $15370.0100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 4 5.000000 $375.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 13 13 23.005479 $1725.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 20 20 40.000000 $3000.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 8.857143 $664.2800 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 10 11 22.000000 $1650.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 12 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 4 4 7.500000 $562.5000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 42 44 72.876256 $4044.6300 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 16 16 30.005556 $1665.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 305 306 583.335025 $43750.1400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 293 296 569.675884 $42725.7000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 100 100 198.500000 $14887.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 47 47 92.005479 $6900.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 26 26 52.000000 $3900.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 116 117 222.159294 $16661.9600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 522 524 968.482971 $53750.8200 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 186 188 357.043985 $19815.9500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 249 258 462.147946 $34661.1000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 6 6 12.000000 $900.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 2.966667 $148.3400 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 3 3 14.690476 $734.5300 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 56 59 25.350004 $1294.1400 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.111111 $5.6700 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 8 8 12.846032 $655.7900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 54 54 39.808522 $2032.2200 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 278 294 189.054220 $9651.2400 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.183333 $9.3600 $51.0400
PSTF -97164 PT RE-EVAL EST PLAN CARE 32 33 12.266668 $626.2200 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.111111 $5.6700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 24 25 14.657838 $748.2800 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.466667 $23.8300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 145 155 93.918606 $4794.5800 $51.0500
PSTH -97163GT PT EVAL HIGH COMPLEXITY 1 1 0.477778 $24.3900 $51.0500
PSTH -97163TL PT EVAL HIGH COMPLEXITY 1 1 0.227778 $11.6300 $51.0500
PSTH -97163TLGT PT EVAL HIGH COMPLEXITY 1 1 0.183333 $9.3600 $51.0400
SCREEN-T1023 SCREENING 33 33 32.166667 $1608.3400 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 2.000000 $102.1000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 11 11 9.537747 $486.9000 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 299 310 173.483454 $8856.3500 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.655556 $84.5200 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 5.072222 $258.9400 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 15 15 11.396576 $581.8000 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 28 29 25.488889 $1301.2100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 28 28 48.497620 $2160.5700 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.277778 $12.3800 $44.5500
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Subtotal (Total Children Is Unduplicated) 2280 3676 5177.378260 $320103.2100 $61.8300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 74 79 73.956738 $369782.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 1.755555 $87.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 6 6 6.983332 $349.1600 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 18 18 15.977169 $1144.1200 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 30 31 32.188890 $7403.4700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 663 827 736.230067 $36811.6100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 74 96 63.448777 $3172.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 167 217 180.953062 $4523.8400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1064 1175 2043.550397 $102177.4900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 55 59 94.125399 $4706.2900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 130 147 143.488887 $3587.2200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 920 1035 1417.162683 $70858.0400 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 72 74 83.928572 $4196.4300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 74 120 100.683333 $2517.0800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 382 429 623.963884 $31198.1500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 45 46 58.337302 $2916.8700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 35 61 64.572225 $1614.3100 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1197 1264 1660.950001 $83047.5200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 92 98 110.564287 $5528.2200 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 133 149 138.865872 $3471.6400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 153 204 1322.500027 $33062.4700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4313 4678 30559.088253 $1527954.4000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 478 522 2536.745249 $126837.2500 $50.0000
INTR -T1013 INTERPRETER 192 235 640.425396 $32021.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2588 3375 19381.788236 $193817.8800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 668 731 3917.787322 $279886.6900 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 22 23 150.904763 $10780.6400 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 119 129 751.248813 $42971.4100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 5 5 16.642856 $951.9700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 10 10 28.157144 $2011.5500 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 68 69 376.403174 $26890.2500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 537 596 3190.371444 $227920.1500 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 16 16 79.395240 $5672.0000 $71.4400
PHY -97110HM PT SESSION BY PT ASST 53 61 365.285717 $20879.7400 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 10 10 52.428572 $3745.5100 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 58 60 266.769048 $19057.9800 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.466667 $95.3400 $65.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 2.252055 $513.4800 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.122222 $27.8600 $227.9600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 1.844445 $841.0900 $456.0100
SENS -V5264 EARMOLD 10 10 8.556164 $154.0100 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 897 990 5718.231525 $408510.3400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 26 27 126.542857 $9040.2200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 3 7.571428 $433.0800 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 21 24 118.238095 $8446.9200 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 68 73 404.000003 $28861.7400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 34 37 218.357143 $3030.8000 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.733333 $10.1800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.666667 $24.6700 $37.0000
TRAV -TRAVS Travel by mile 872 1326 74210.986025 $33023.8900 $0.4500
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Subtotal (Total Children Is Unduplicated) 6434 19158 152107.196315 $3786568.9000 $24.8900
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Total 23167 164657.044422 $4300918.8200 $26.1200
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Number of Children (Unduplicated) With at Least One Authorization 7553