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: 10-01-21 and 12-31-21 Date of Report: 02-04-22 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 23166 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 1 1 0.788889 $29.1900 $37.0000
SCONLY-SCONLY *SERVICE COORDINATION ONLY 310 314 690.169054 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 83 86 7141.565079 $264237.9000 $37.0000
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Subtotal (Total Children Is Unduplicated) 393 401 7832.523022 $264267.0900 $33.7400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 98 112 85.001239 $4122.5600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 18 18 16.110318 $897.5000 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 4.000000 $94.0000 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 193 196 193.767362 $4553.5300 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 12 12 6.372221 $92.9100 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 31 31 19.221688 $451.7100 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 3.855556 $37.7500 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 3.000000 $29.3700 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 11 11 6.494445 $186.5200 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 2.000000 $89.5200 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 12 12 10.188889 $864.4300 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 4 4 4.000000 $204.2800 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 21 21 17.161112 $235.2800 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 23 23 32.134921 $671.3000 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 14 14 18.472690 $831.2700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 12 12 8.097716 $931.2400 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 18 20 27.221003 $1361.0500 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 178 181 301.541879 $15077.0900 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 21 39.500000 $2962.5000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 10 10 16.022222 $1201.6700 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 9.000000 $675.0000 $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 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 12 12 14.172907 $1062.9600 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 8 8 15.500000 $1162.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 49 50 100.051958 $5552.8800 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 9 9 16.147945 $896.2100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 329 333 636.285513 $47721.4400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 216 218 406.887282 $30516.5200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 118 118 233.714286 $17528.5700 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 39 40 77.142857 $5785.7200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 15 16 28.000000 $2100.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 119 122 220.125637 $16509.4100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 486 495 946.016346 $52503.9300 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 156 156 287.779453 $15971.7500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 192 203 395.222309 $29641.6700 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 6 6 12.000000 $900.0000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.142857 $7.1500 $50.0200
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 6.859524 $342.9800 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 47 51 23.986791 $1224.5300 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 1.166666 $59.5600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 3.600000 $183.7800 $51.0500
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 1 1 0.022222 $1.1300 $51.0000
OCTH -97166 OT EVAL MODERATE COMPLEXITY 52 54 40.012862 $2042.6600 $51.0500
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.005556 $0.2900 $51.4600
OCTH -97167 OT EVAL HIGH COMPLEXITY 253 264 168.202751 $8586.7500 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.500000 $25.5300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 29 30 9.258220 $472.6400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 32 32 21.614537 $1103.4300 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 166 179 89.215017 $4554.4400 $51.0500
SCREEN-T1023 SCREENING 44 45 44.255556 $2212.7800 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.388889 $479.3000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 8 8 5.533333 $282.4800 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 278 286 150.181763 $7666.8100 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 4.538889 $231.7100 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 1.400000 $71.4700 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 13 13 8.149696 $416.0400 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 22 22 20.727778 $1058.1500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 55 58 39.188587 $1745.8600 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 2.000000 $89.1000 $44.5500
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Subtotal (Total Children Is Unduplicated) 2263 3598 4883.161248 $297587.8000 $60.9400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 69 76 70.401966 $352008.5000 $4999.9800
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 7 7 6.566668 $328.3400 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 19 20 19.277778 $963.8900 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.266667 $87.2300 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 24 24 42.152740 $2902.6300 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 25 25 31.748412 $7302.1300 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 671 839 745.296992 $37265.0100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 101 123 90.699252 $4534.9800 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 206 258 210.345846 $5258.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1129 1251 2107.837504 $105391.8900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 77 91 112.661903 $5633.0900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 121 129 123.256351 $3081.4200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 854 962 1264.988890 $63249.4600 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 95 96 123.867462 $6193.3800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 54 95 67.551582 $1688.7800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 398 428 565.241670 $28262.0800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 56 59 66.963493 $3348.1800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 27 44 42.488886 $1062.2200 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1205 1274 1608.357118 $80417.8700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 110 115 115.791263 $5789.5300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 122 127 128.465876 $3211.6500 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 139 150 1319.750005 $32993.7400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4558 4911 30472.939388 $1523647.0300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 487 516 2480.041287 $124002.0200 $50.0000
INTR -T1013 INTERPRETER 174 188 639.724295 $31986.2200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2543 3192 17188.824675 $171888.2600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 633 673 3745.793670 $267599.4800 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 28 28 133.572223 $9542.4200 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 128 136 833.045240 $47650.1800 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 9 10 37.147619 $2124.8400 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 13 13 37.961906 $2712.0000 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 55 58 344.634919 $24620.7100 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 583 633 3408.323408 $243490.6200 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 28 31 88.071429 $6291.8500 $71.4400
PHY -97110HM PT SESSION BY PT ASST 47 54 313.428569 $17915.5700 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 5 5 28.214286 $1612.7300 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 10 10 27.511904 $1965.4500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 43 44 174.142854 $12440.7600 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.197260 $77.8200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 3 3 2.513394 $573.0600 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 3 3 2.460274 $560.9500 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 6 6 5.755556 $2624.5500 $456.0000
SENS -V5264 EARMOLD 22 23 19.235616 $346.2400 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 945 1015 5835.139270 $416862.3200 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 33 34 158.239684 $11304.6200 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 3.142857 $179.7700 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 18 18 110.601587 $7901.3800 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 76 80 479.052383 $34223.4800 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 17 19 105.642861 $1466.3200 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.933333 $68.4700 $13.8800
TRAV -TRAVS Travel by mile 882 1264 70444.973622 $31348.0200 $0.4500
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Subtotal (Total Children Is Unduplicated) 6773 19167 145992.243693 $3748115.7600 $25.6700
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Total 23166 158707.927963 $4309970.6500 $27.1600
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Number of Children (Unduplicated) With at Least One Authorization 7900