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: 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 21954 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
SCONLY-SCONLY *SERVICE COORDINATION ONLY 242 244 352.182552 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 41 42 4457.526984 $164928.5000 $37.0000
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Subtotal (Total Children Is Unduplicated) 281 286 4809.709536 $164928.5000 $34.2900
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 101 114 85.476220 $4145.5900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 17 18 15.661111 $872.4800 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 5 5 4.911111 $115.4100 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 274 274 286.206348 $6725.8500 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 6 6 4.827778 $70.3900 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 37 37 24.288887 $570.7800 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 9 9 5.655554 $55.3700 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 3 3 3.000000 $29.3700 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 12 12 9.261110 $265.9800 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 5 5 4.911111 $219.8200 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 5 5 4.866667 $412.8900 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 1.000000 $51.0700 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 23 23 19.394443 $265.9000 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 16 16 24.928571 $520.7600 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 8 8 5.366666 $241.5000 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 6 6 3.722222 $428.0500 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 21 23 28.287366 $1414.3700 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 133 135 212.596804 $10629.8500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 19 19 33.783333 $2533.7500 $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 3 3 6.000000 $450.0000 $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 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 10 10 12.024962 $901.8700 $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 33 33 56.334932 $3126.5900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 9 9 16.082192 $892.5600 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 330 335 644.571227 $48342.8600 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 217 219 406.969474 $30522.6800 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 119 119 235.714286 $17678.5700 $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 15 27.000000 $2025.0000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 122 125 224.002350 $16800.1600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 483 493 947.373684 $52579.2600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 156 156 287.612330 $15962.4700 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 190 201 395.151076 $29636.3300 $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 4 4 11.652380 $582.6200 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 49 54 33.373201 $1703.7100 $51.0500
OCTF -97168GT OT RE-EVAL EST PLAN CARE 2 2 1.100000 $56.1600 $51.0500
OCTF -97168TLGT OT RE-EVAL EST PLAN CARE 1 1 0.188889 $9.6400 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 6 6 4.244445 $216.6800 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 2 2 11.917460 $608.3900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 27 27 17.555863 $896.2400 $51.0500
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 253 268 230.601432 $11772.1900 $51.0500
OCTH -97167GT OT EVAL HIGH COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
OCTH -97167TL OT EVAL HIGH COMPLEXITY 1 1 0.166667 $8.5100 $51.0600
PSTF -97164 PT RE-EVAL EST PLAN CARE 44 46 24.738283 $1262.9000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 17 17 12.851706 $656.0800 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 2 2 1.127778 $57.5700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 152 167 79.948104 $4081.3800 $51.0500
SCREEN-T1023 SCREENING 25 25 25.155556 $1257.7800 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 11 11 11.000000 $561.5500 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 14 15 16.894444 $862.4600 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.355556 $18.1500 $51.0600
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 243 252 153.599884 $7841.2900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 1.666666 $85.0800 $51.0500
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.372222 $70.0500 $51.0500
SPCH -92523TLGT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 0.284931 $14.5400 $51.0400
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 39 46 42.705556 $2180.1200 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 69 71 56.808141 $2530.7900 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $44.5500 $44.5500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.472222 $21.0400 $44.5500
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Subtotal (Total Children Is Unduplicated) 2165 3542 4914.571137 $295898.2200 $60.2100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 68 74 80.810340 $404051.0000 $4999.9900
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 28 28 27.722223 $1386.1200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 18 18 59.448411 $4093.6200 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 35 35 47.299205 $10878.8200 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 697 880 786.726871 $39336.5200 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 116 140 100.792904 $5039.6700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 197 247 202.944514 $5073.6300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1149 1242 2092.488701 $104624.4900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 71 79 128.640478 $6432.0300 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 96 99 115.238890 $2880.9800 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 830 930 1324.540478 $66227.0500 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 71 74 93.726989 $4686.3700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 53 85 93.305557 $2332.6400 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 356 401 654.764291 $32738.2500 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 48 49 65.122227 $3256.1300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 21 37 41.511112 $1037.7800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1090 1137 1559.255967 $77962.8600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 104 107 126.287307 $6314.4000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 100 103 119.220634 $2980.5200 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 103 115 1092.857138 $27321.4400 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 4408 4817 32661.071749 $1633054.4400 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 442 465 2402.893861 $120144.7400 $50.0000
INTR -T1013 INTERPRETER 153 171 541.400488 $27070.0200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2302 2809 16988.625709 $169886.4000 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 588 639 3919.130136 $279982.9600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 14 14 91.123809 $6509.8800 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 141 148 1139.657146 $65188.4100 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 8 9 38.519048 $2203.3000 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 13 13 40.466666 $2890.9300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 52 54 365.311108 $26097.8400 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 585 642 3812.511103 $272366.0000 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 13 17 120.590476 $8614.9900 $71.4400
PHY -97110HM PT SESSION BY PT ASST 76 78 608.852384 $34801.9800 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 3 4 21.750000 $1243.2400 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 17 17 39.442857 $2817.8000 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 45 49 197.699995 $14123.7000 $71.4400
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 1.000000 $114.0000 $114.0000
SENS -V5060 BEHIND EAR HEARING AID 3 3 3.000000 $684.0000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 3 3 3.000000 $1368.0000 $456.0000
SENS -V5264 EARMOLD 18 18 16.188889 $291.4000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 839 909 5754.226926 $411082.3100 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 14 14 56.580951 $4042.1400 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 12.000000 $686.4000 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 21 22 129.995236 $9286.8600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 54 59 272.215077 $19447.0500 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 63 65 401.452381 $5572.1600 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.771429 $163.3900 $13.8800
TRAV -TRAVS Travel by mile 839 1200 82245.617514 $36599.3000 $0.4500
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Subtotal (Total Children Is Unduplicated) 6394 18126 160708.799175 $3964987.9300 $24.6700
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Total 21954 170433.079848 $4425814.6400 $25.9700
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Number of Children (Unduplicated) With at Least One Authorization 7064