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
Eligibility Filter: Program Patients
With the filters selected there were 34809 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 358 372 2301.161911 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 1 1 2.733333 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 94 96 7242.892061 $267986.9900 $37.0000
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Subtotal (Total Children Is Unduplicated) 451 469 9546.787305 $267986.9900 $28.0700
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 145 154 123.926254 $6010.4200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 15 15 13.707763 $774.3500 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 1.522223 $30.0000 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 227 229 234.127779 $5499.6600 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 19 20 11.011112 $152.7300 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 38 38 21.702206 $514.3400 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 37 38 30.960787 $281.1300 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $9.9600 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 37 38 27.153176 $755.6800 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 4 4 4.000000 $153.8800 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 32 35 34.345708 $2913.9100 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 11 11 11.252055 $574.6400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 38 39 26.586510 $444.0000 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 38 38 46.706023 $1046.2200 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 30 31 20.908525 $940.8900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 9 9 4.232039 $486.6900 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 34 40 54.657078 $2732.8600 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 5 7 8.411111 $420.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 243 245 413.226465 $20661.3300 $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 16 16 29.005479 $2175.4100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 29 29 55.005556 $4125.4200 $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 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 12 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 18 19 35.005556 $2625.4200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 6 6 11.000000 $825.0000 $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 63 66 108.147184 $6002.1700 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 20 20 35.011112 $1943.1200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 484 485 933.351462 $70001.3800 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 465 470 898.466294 $67384.9900 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 162 162 320.533333 $24040.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 78 78 154.005479 $11550.4100 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 41 42 80.000000 $6000.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 192 193 359.455183 $26959.1600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 836 839 1574.226804 $87369.6100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 281 283 530.576859 $29447.0300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 389 404 737.798630 $55334.9100 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 8 8 16.000000 $1200.0000 $75.0000
NUTR -97802 NUTRITIONAL EVAL, INITIAL 2 2 3.433334 $171.6700 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 18.523810 $926.2000 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 79 82 35.816672 $1828.4700 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 0.227778 $11.6300 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 11 11 15.979365 $815.7400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 80 81 61.076777 $3117.9700 $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 444 471 297.386486 $15181.6000 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167TLGT OT EVAL HIGH COMPLEXITY 1 1 0.183333 $9.3600 $51.0400
PSTF -97164 PT RE-EVAL EST PLAN CARE 42 43 15.138587 $772.8400 $51.0500
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.111111 $5.6700 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 37 38 28.320536 $1445.7600 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.466667 $23.8300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 221 236 136.874615 $6987.4700 $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 2 2 1.183333 $60.4100 $51.0500
SCREEN-T1023 SCREENING 62 63 63.300000 $3165.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 5 6.686496 $100.3000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 7.438889 $379.7600 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 15 16 11.948859 $610.0000 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 544 571 321.887338 $16432.3900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 3.772223 $192.5800 $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 17 17 11.667200 $595.6200 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 47 49 44.588889 $2276.2600 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 62 62 70.572353 $3144.0000 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPCH -92610TLGT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.277778 $56.9300 $44.5500
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Subtotal (Total Children Is Unduplicated) 3612 5937 8187.523095 $503987.9700 $61.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 118 128 116.484526 $582421.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 11 11 11.717459 $585.8700 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 33 35 60.352434 $3017.6200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 24 24 20.699391 $1482.2800 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 51 52 54.329757 $12495.8800 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 999 1258 1156.941724 $57847.2500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 121 161 107.821760 $5391.0900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 267 347 291.627795 $7290.7300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1580 1739 3056.730551 $152836.4700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 93 97 145.189683 $7259.5000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 185 206 186.215076 $4655.3700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1374 1545 2136.526974 $106826.2600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 101 103 113.250796 $5662.5500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 94 158 135.127778 $3378.2000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 554 614 902.767058 $45138.2800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 56 57 73.203969 $3660.2000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 43 74 76.527780 $1913.2000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1879 1978 2675.865881 $133793.3200 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 137 143 172.569843 $8628.4900 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 189 209 190.910314 $4772.7500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 227 307 2108.813525 $52720.3000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6089 6639 43248.636754 $2162431.7100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 614 663 3306.642869 $165332.1100 $50.0000
INTR -T1013 INTERPRETER 224 272 718.068253 $35903.4200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3582 4697 27016.793844 $270167.9300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1076 1183 6409.897645 $457923.0700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 41 43 268.752382 $19199.6500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 170 186 1056.679770 $60442.0500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 8 8 30.680952 $1754.9500 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 13 15 43.838096 $3131.7900 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 84 86 453.959523 $32430.9000 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 862 940 5103.877804 $364620.9800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 36 37 177.408733 $12674.0700 $71.4400
PHY -97110HM PT SESSION BY PT ASST 67 75 450.464289 $25748.5500 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 4 11.285714 $645.0900 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 14 14 76.261905 $5448.1600 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 73 76 355.721431 $25412.7400 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 6 6.466667 $420.3400 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.019178 $2.1900 $114.1300
SENS -V5050 IN EAR MONAURAL HEARING AID 7 7 7.815145 $1781.8700 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 5 5 4.622222 $1053.8600 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 11 11 7.605023 $3467.9300 $456.0000
SENS -V5264 EARMOLD 39 41 39.913557 $718.4500 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1830 2031 11607.524399 $829241.5100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 61 65 287.504765 $20539.3400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 4 8.714285 $498.4600 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 28 31 162.076191 $11578.7100 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 93 100 524.573814 $37475.5400 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 54 58 342.000000 $4746.9600 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 13.733333 $190.6200 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.666667 $24.6700 $37.0000
TRAV -TRAVS Travel by mile 1217 1856 93762.199322 $41724.1800 $0.4500
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Subtotal (Total Children Is Unduplicated) 9539 28403 209298.078606 $5798508.8400 $27.7000
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Total 34809 227032.389006 $6570483.8000 $28.9400
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Number of Children (Unduplicated) With at Least One Authorization 11315