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 17560 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 351 359 3580.327774 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 14 14 1411.700000 $52232.9000 $37.0000
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Subtotal (Total Children Is Unduplicated) 369 377 4996.105552 $52383.7800 $10.4800
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 113 124 94.776223 $4596.6500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 7 7 7.216667 $407.6700 $56.4900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 0.022222 $0.4400 $19.6900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 6 6 6.022222 $141.4600 $23.4900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 1.377778 $19.1100 $13.8700
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 3.094444 $73.3400 $23.7000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 6 6 2.105555 $19.1200 $9.0800
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 2 2 2.000000 $19.9200 $9.9600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 6 6 2.105555 $58.6000 $27.8300
AUDE -92585 AUD EVOKED RESPONSE (COMP) 7 7 2.911718 $247.0200 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 7 7 4.749999 $79.3200 $16.7000
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 3 3 3.000000 $67.2000 $22.4000
AUDE -V5010 ASSESSMENT FOR HEARING AID 4 4 2.122830 $95.5300 $45.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 36 42 55.503957 $2775.2000 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 255 256 450.157220 $22507.8600 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 6.427778 $482.0900 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 4 4 6.427778 $482.0900 $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 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 18 18 31.683257 $1758.4200 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 2.005556 $111.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 67 68 129.010958 $9675.8300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 63 64 117.016437 $8776.2400 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 19 19 36.033333 $2702.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 6 6 12.000000 $900.0000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 5 5 8.000000 $600.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 45 45 81.021916 $6076.6500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 132 133 247.167121 $13717.7800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 58 58 102.032874 $5662.8300 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 48 51 103.000000 $7725.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 7 7 3.500000 $178.6800 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 6.180158 $315.4900 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 50 52 34.499998 $1761.2100 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 2.000000 $102.1000 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 3 3 1.338888 $68.3500 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 0.850000 $43.3900 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 22 23 14.495280 $739.9800 $51.0500
SCREEN-T1023 SCREENING 1 1 1.000000 $50.0000 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 2 3 3.000000 $45.0000 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 3 3 2.194444 $112.0200 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $51.0500 $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 58 61 43.365079 $2213.7900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $102.1000 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $153.1500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 15 16 11.783334 $524.9500 $44.5500
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Subtotal (Total Children Is Unduplicated) 842 1158 1671.283912 $97600.9900 $58.4000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 26 28 40.392987 $201965.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 3 2.277777 $113.8900 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 14 15 21.137302 $1056.8700 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 7 7 5.981430 $428.3300 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 15 16 8.972222 $2063.6100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 889 1110 1009.611598 $50480.7600 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 124 163 105.499540 $5274.9900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 135 148 101.671689 $2541.8300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1524 1673 2874.476678 $143723.7700 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 102 112 122.140472 $6107.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 161 170 161.480153 $4036.9900 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1268 1445 1904.513095 $95225.6200 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 118 121 112.025393 $5601.2500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 83 144 139.655554 $3491.3900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 501 559 782.640833 $39132.0400 $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 1675 1777 2304.497231 $115224.8800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 141 144 132.429361 $6621.4500 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 149 153 159.580156 $3989.5000 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 21 22 105.107144 $2627.6800 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 2.142857 $107.1500 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1152 1281 8166.218943 $408311.2000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 53 56 312.133333 $15606.6700 $50.0000
INTR -T1013 INTERPRETER 186 232 681.604761 $34080.2400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3333 4174 24135.409216 $241354.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 94 99 533.428559 $38108.1500 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 7 7 54.757142 $3911.8500 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 5 5 53.571428 $3064.3000 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 2.333333 $166.6900 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 4 4 22.895238 $1635.6400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 75 79 476.352380 $34030.6400 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 5 6 22.576190 $1612.8400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 5 5 21.142857 $1208.5200 $57.1600
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 2.866667 $204.8000 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 5 6 6.000000 $390.0000 $65.0000
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.355556 $81.0800 $228.0300
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 3.988889 $1818.9400 $456.0000
SENS -V5264 EARMOLD 11 13 8.045662 $144.8200 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 186 207 1160.591258 $82912.6900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 6 7 32.142858 $2296.2900 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 8.571429 $490.2800 $57.2000
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 13 13 67.095239 $4793.2900 $71.4400
SPL -92508 GROUP SPL SESSION PER CHILD 11 11 56.002380 $777.3100 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 0.666667 $24.6700 $37.0000
TRAV -TRAVS Travel by mile 1286 1893 95737.959487 $42603.3900 $0.4500
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Subtotal (Total Children Is Unduplicated) 6248 16025 141762.387388 $1613246.0700 $11.3800
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Total 17560 148429.776852 $1763230.8300 $11.8800
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Number of Children (Unduplicated) With at Least One Authorization 6809