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
Eligibility Filter: Program Patients
With the filters selected there were 35005 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 396 402 1181.444450 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 104 107 10128.353967 $374749.0900 $37.0000
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Subtotal (Total Children Is Unduplicated) 499 510 11310.587306 $374778.2800 $33.1400
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 164 183 126.279548 $6124.5500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 31 31 30.110318 $1677.4400 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 11 11 11.194444 $263.0700 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 333 336 336.961806 $7918.6000 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 29 29 24.244443 $353.4800 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 58 58 41.832799 $983.0700 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 28 28 17.511112 $171.4300 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 11 11 12.000000 $117.4800 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 36 36 27.105557 $778.4800 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 13 13 16.000000 $716.1600 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 38 38 37.302587 $3164.7400 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 17 17 19.000000 $970.3300 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 42 42 32.538890 $446.1100 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 53 53 76.287302 $1593.6400 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 26 26 26.957622 $1213.0900 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 19 19 11.438812 $1315.4600 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 22 24 32.286756 $1614.3400 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 3 4 6.011111 $300.5600 $50.0000
EXIT -EXIT EXIT ASSESSMENT 269 272 475.533943 $23776.7000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 35 35 63.733334 $4780.0100 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 16 16 24.211111 $1815.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 10 10 18.000000 $1350.0000 $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 10 10 20.000000 $1500.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 16 16 16.194976 $1214.6200 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 13 13 24.500000 $1837.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 80 84 160.176844 $8889.8100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 13 13 22.153424 $1229.5100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 505 509 980.285513 $73521.4400 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 317 319 595.947557 $44696.0300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 194 194 385.180953 $28888.5800 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 62 63 121.709524 $9128.2200 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 32 33 62.966667 $4722.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 170 173 312.133857 $23410.0100 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 727 739 1419.549222 $78785.0000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 225 226 413.865299 $22969.5000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 277 296 575.255185 $43144.1300 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 9 9 18.000000 $1350.0000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.142857 $7.1500 $50.0200
NUTR -97802 NUTRITIONAL EVAL, INITIAL 1 1 0.072222 $3.6100 $49.9800
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 5 5 6.859524 $342.9800 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 69 76 36.853459 $1881.3800 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 1.166666 $59.5600 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 8.600000 $439.0300 $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 81 84 61.840412 $3156.9600 $51.0500
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.172222 $8.7900 $51.0400
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 1 1 0.005556 $0.2900 $51.4600
OCTH -97167 OT EVAL HIGH COMPLEXITY 414 435 277.528353 $14167.8100 $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 32 33 9.819331 $501.2800 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 51 53 37.071692 $1892.5200 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 4 4 13.714286 $700.1200 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 257 282 160.059210 $8171.0300 $51.0500
SCREEN-T1023 SCREENING 64 65 64.255556 $3212.7800 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 3 3 0.483562 $7.2500 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 15 15 15.800000 $806.5900 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 24 26 26.230156 $1339.0400 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 500 525 257.135416 $13126.7900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 6.211111 $317.0800 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 2.400000 $122.5200 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 25 25 16.496956 $842.1700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 61 62 60.783334 $3102.9900 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 95 98 80.358592 $3579.9800 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 4 2.432877 $108.3900 $44.5500
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Subtotal (Total Children Is Unduplicated) 3614 5823 7751.476088 $465310.3400 $60.0300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 116 125 130.262424 $651310.5000 $4999.9900
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 11 11 9.122223 $456.1200 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 47 48 57.407677 $2870.3900 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.266667 $87.2300 $68.8600
AUD -92633 AUD REHAB POSTLING HEARING LOSS 29 29 46.313851 $3189.1700 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 54 54 62.076428 $14277.5700 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1003 1274 1192.846941 $59642.5700 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 155 201 156.392479 $7819.6500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 319 401 343.485241 $8587.1700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1683 1855 3026.151386 $151307.5200 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 105 120 169.689681 $8484.4800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 175 188 158.773016 $3969.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1335 1492 1977.161510 $98858.0800 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 138 140 189.285714 $9464.2900 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 81 133 84.940467 $2123.4900 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 570 619 821.274214 $41063.7400 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 68 71 81.397620 $4069.8900 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 37 60 62.072219 $1551.8000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1876 1981 2508.739264 $125436.9800 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 162 168 186.740471 $9337.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 176 182 166.282542 $4157.0700 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 180 193 1894.464292 $47361.6000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6515 7013 43220.847758 $2161042.3200 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 625 660 3133.049224 $156652.4100 $50.0000
INTR -T1013 INTERPRETER 207 222 728.224295 $36411.2200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3560 4505 24295.497465 $242954.9800 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 1030 1111 6225.081770 $444719.7700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 56 58 251.503968 $17967.4700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 186 200 1227.869053 $70234.1100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 11 12 52.004762 $2974.6600 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 20 20 78.638097 $5617.9000 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 75 79 447.753968 $31987.5400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 917 999 5296.005554 $378346.5800 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 42 46 131.723811 $9410.3800 $71.4400
PHY -97110HM PT SESSION BY PT ASST 72 80 475.174205 $27160.9300 $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 13 13 35.226190 $2516.5600 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 56 58 228.552378 $16327.7800 $71.4400
PHY -97110TLHM PT SESSION BY PT ASST 1 1 6.428571 $367.4600 $57.1600
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 1.197260 $77.8200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 1.054794 $120.2500 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 5 5 2.770928 $631.7700 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 7 7 6.504719 $1483.0900 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 15 15 13.091477 $5969.7200 $456.0000
SENS -V5264 EARMOLD 46 48 41.135083 $740.4300 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1915 2086 11579.595647 $827246.2400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 72 76 327.681749 $23409.5500 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 3 3 10.571428 $604.6800 $57.2000
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 5.285714 $302.3400 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 23 23 133.111111 $9509.4600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 105 110 638.083335 $45584.6500 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 32 35 198.238100 $2751.5400 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 4.933333 $68.4700 $13.8800
TELEC -TELEC TELECONFERENCE,PROVIDER TO FAMILY,P 1 1 2.333333 $86.3300 $37.0000
TRAV -TRAVS Travel by mile 1270 1828 102942.086085 $45809.2300 $0.4500
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Subtotal (Total Children Is Unduplicated) 10125 28672 215095.615778 $5826125.9800 $27.0900
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Total 35005 234157.679172 $6666214.6000 $28.4700
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Number of Children (Unduplicated) With at Least One Authorization 11779