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: 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 21346 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 4 4 4.077778 $150.8800 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 275 282 3514.365078 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 54 54 3977.295238 $147159.9300 $37.0000
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Subtotal (Total Children Is Unduplicated) 333 340 7495.738094 $147310.8000 $19.6500
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 82 91 71.192248 $3452.8200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 14 14 20.285323 $1145.9200 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 5.000000 $98.5500 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 25 25 24.050000 $564.9300 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 5.177778 $71.8200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 44 44 41.263894 $977.9600 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 7 7 4.638889 $42.1200 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 5 5 5.000000 $49.8000 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 9 9 6.638889 $184.7600 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 5.000000 $192.3500 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 9 10 8.333333 $707.0000 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 8 8 7.877778 $402.3200 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 23 23 20.638889 $344.6700 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 15 15 30.285714 $678.4000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 16.328571 $734.7900 $45.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 29 34 47.551598 $2377.5900 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 1 1 2.000000 $100.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 178 179 313.300045 $15665.0000 $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 14 14 27.000000 $2025.0000 $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 8 8 14.000000 $1050.0000 $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 47 50 86.026941 $4774.4900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 15 15 28.005556 $1554.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 305 306 583.835025 $43787.6400 $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 27 27 54.000000 $4050.0000 $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 517 519 966.970641 $53666.8800 $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 244 253 461.135616 $34585.1800 $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 0.100000 $5.0000 $50.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 16.495237 $824.7700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 50 54 20.844448 $1064.1300 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.644444 $32.9000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 5.000000 $255.2500 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 47 47 36.663318 $1871.6600 $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 252 268 173.251249 $8844.4800 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 28 28 11.800002 $602.4000 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.077778 $3.9700 $51.0600
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 1.277778 $65.2300 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 22 22 12.169256 $621.2500 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 121 129 87.168732 $4449.9800 $51.0500
SCREEN-T1023 SCREENING 41 41 41.000000 $2050.0000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 8.394444 $428.5300 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 9 9 5.762558 $294.1900 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 280 297 176.595621 $9015.2700 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 3.218874 $164.3200 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 5.000000 $255.2500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 11 11 9.266666 $473.0600 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 7 7 4.383334 $223.7700 $51.0500
SPCH -92524TLGT BEHAV & QUAL ANALYSIS OF VOICE AND 1 1 1.000000 $51.0500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 51 52 54.631630 $2433.8600 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.142466 $50.9000 $44.5500
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Subtotal (Total Children Is Unduplicated) 2026 3497 5090.309205 $317247.6800 $62.3200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 62 68 63.882270 $319412.0000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 2.888889 $144.4500 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 7 7 6.727777 $336.3900 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 23 23 19.959437 $1429.2900 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 24 25 32.086421 $7379.8500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 654 813 759.562629 $37978.2500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 81 102 63.354335 $3167.7300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 168 220 195.568140 $4889.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1042 1153 1985.646516 $99282.2400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 69 79 84.794442 $4239.7100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 117 126 114.761106 $2869.0200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 846 961 1256.558724 $62827.9000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 74 76 69.679363 $3483.9500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 62 106 105.977775 $2649.4400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 335 373 505.682500 $25284.1200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 36 36 36.638887 $1831.9400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 22 38 37.722224 $943.0600 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1080 1139 1439.194838 $71959.7300 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 98 100 81.969838 $4098.4800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 111 116 115.976982 $2899.4200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 202 244 2289.861932 $57246.5200 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 3948 4327 27745.454047 $1387273.6400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 458 484 2447.012683 $122350.6800 $50.0000
INTR -T1013 INTERPRETER 186 234 629.676189 $31483.8200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2332 2925 16862.437890 $168624.4800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 517 577 3231.236476 $230839.6400 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 24 24 133.552380 $9540.9900 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 111 115 800.154757 $45768.8800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 8 9 30.790475 $1761.2200 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 14 16 90.771430 $6484.7300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 63 67 240.802376 $17202.9500 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 411 471 2739.255930 $195692.5600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 15 15 106.485713 $7607.3500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 44 50 292.785712 $16735.6500 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 2 2 5.000000 $285.8000 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 8 9 25.766665 $1840.7600 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 34 35 102.144442 $7297.1900 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 3.000000 $195.0000 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.443836 $101.1900 $227.9800
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.066667 $1398.4200 $456.0000
SENS -V5264 EARMOLD 7 7 5.855555 $105.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 744 831 4752.184889 $339496.3000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 30 32 172.414287 $12317.2800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 4 12.642856 $723.1700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 14 15 69.476190 $4963.3800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 62 65 286.995236 $20502.9500 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 52 53 313.519042 $4351.6500 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.000000 $83.2800 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.666667 $24.6700 $37.0000
TRAV -TRAVS Travel by mile 882 1326 68702.716080 $30572.7100 $0.4500
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Subtotal (Total Children Is Unduplicated) 5903 17509 139080.803495 $3379978.3400 $24.3000
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Total 21346 151666.850794 $3844536.8200 $25.3500
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Number of Children (Unduplicated) With at Least One Authorization 6640