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
Eligibility Filter: Program Patients
With the filters selected there were 32680 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 377 385 3689.378567 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 88 88 6823.339682 $252463.5700 $37.0000
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Subtotal (Total Children Is Unduplicated) 468 477 10516.796027 $252614.4500 $24.0200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 133 147 112.194487 $5441.4300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 25 25 31.924212 $1803.4000 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 9.111111 $179.5800 $19.7100
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 40 40 37.300000 $876.1800 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 16 16 14.983334 $207.8200 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 65 65 55.141671 $1306.8600 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 26 23.834126 $216.4100 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 8 8 8.000000 $79.6800 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 32 32 26.057142 $725.1700 $27.8300
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 9 9 8.088889 $311.1800 $38.4700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 27 29 26.582353 $2255.2400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 17 17 16.383334 $836.7000 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 48 48 43.245237 $722.1900 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 40 40 57.574603 $1289.6700 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 25 25 30.390366 $1367.5600 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 1.194521 $137.3700 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 37 44 59.503957 $2975.2000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 4 6 8.022222 $401.1100 $50.0000
EXIT -EXIT EXIT ASSESSMENT 260 261 455.718331 $22785.9100 $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 18 18 33.427778 $2507.0900 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 31 31 57.433334 $4307.5100 $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 12 13 26.000000 $1950.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 17 18 33.005556 $2475.4200 $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 74 80 135.380061 $7513.6000 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 19 19 33.011112 $1832.1200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 483 484 931.851462 $69888.8800 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 465 470 898.970099 $67422.7700 $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 42 43 82.000000 $6150.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 191 192 359.181210 $26938.6100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 831 834 1572.214474 $87257.9300 $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 385 400 738.286300 $55371.4900 $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 0.344444 $17.2200 $49.9900
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 6 6 17.095237 $854.7700 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 74 79 32.550003 $1661.6900 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.644444 $32.9000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 10.000000 $510.5000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 77 78 55.621254 $2839.4600 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 413 444 292.466601 $14930.4400 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 2.094444 $106.9200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 35 35 14.711111 $751.0000 $51.0500
PSTF -97164TL PT RE-EVAL EST PLAN CARE 1 1 0.077778 $3.9700 $51.0600
PSTH -97161 PT EVAL LOW COMPLEXITY 4 4 3.277778 $167.3300 $51.0500
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 2 3 3.000000 $153.1500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 40 41 25.130366 $1282.9100 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 204 219 138.159904 $7053.0800 $51.0500
SCREEN-T1023 SCREENING 57 59 59.000000 $2950.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 5 6 19.540117 $293.1000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 18 18 17.588888 $897.9100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 16 17 12.018114 $613.5300 $51.0500
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 2.000000 $102.1000 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.083333 $4.2500 $51.0300
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 507 541 312.944743 $15975.9000 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 7.196652 $367.3900 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 9 9 6.000000 $306.3000 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 18 18 14.793226 $755.1900 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 16 16 12.194445 $622.5300 $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 95 100 83.776076 $3732.2500 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.142466 $50.9000 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
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Subtotal (Total Children Is Unduplicated) 3260 5734 8131.578377 $503702.5500 $61.9400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 104 116 109.963689 $549819.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 11 12 13.442856 $672.1400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 31 33 45.784563 $2289.2400 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 32 32 26.951978 $1930.0300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 52 55 55.577517 $12782.8000 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 980 1229 1153.927427 $57696.5500 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 125 164 106.499540 $5324.9900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 271 362 329.559542 $8239.0200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1549 1702 2903.852074 $145192.5400 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 102 112 122.140472 $6107.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 162 172 162.674597 $4066.8500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1282 1460 1917.485316 $95874.2300 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 118 121 112.025393 $5601.2500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 84 145 139.849998 $3496.2500 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 506 564 786.416230 $39320.8100 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 54 54 52.677774 $2633.8700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 29 53 46.766670 $1169.1800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1692 1795 2323.691674 $116184.6000 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 141 144 132.429361 $6621.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 150 155 160.085712 $4002.1400 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 285 344 3381.754801 $84543.8300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 2.142857 $107.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5724 6280 39963.337215 $1998168.3100 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 581 612 3179.807918 $158990.4600 $50.0000
INTR -T1013 INTERPRETER 220 275 755.461904 $37773.1000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3334 4175 24144.694930 $241447.1200 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 880 987 5275.407876 $376875.3800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 45 45 257.409521 $18389.3600 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 158 172 1173.840469 $67143.7100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 10 11 34.004761 $1945.0700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 18 22 103.771429 $7413.4400 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 83 87 349.326182 $24955.9100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 689 778 4462.724965 $318817.2000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 31 32 187.704759 $13409.6200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 67 75 440.285711 $25166.7400 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 5 14.142857 $808.4100 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 10 11 42.438094 $3031.7600 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 49 50 177.011108 $12645.6700 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 6 7 7.000000 $455.0000 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.232877 $26.5500 $114.0100
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 2.000000 $456.0000 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 4 4 2.007611 $457.7300 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 10 11 11.211111 $5112.2600 $456.0000
SENS -V5264 EARMOLD 33 36 42.518950 $765.3400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1591 1794 10225.676113 $730522.8000 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 61 65 325.600000 $23260.8800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 6 33.499999 $1916.1900 $57.2000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 2.642857 $151.1700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 20 21 116.904760 $8351.6900 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 99 102 472.671427 $33767.6700 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 81 82 464.211898 $6443.2600 $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 1286 1894 95744.388058 $42606.2500 $0.4500
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Subtotal (Total Children Is Unduplicated) 8958 26469 202104.302068 $5315057.3600 $26.3000
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Total 32680 220752.676472 $6071374.3600 $27.5000
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Number of Children (Unduplicated) With at Least One Authorization 10051