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
Eligibility Filter: Program Patients
With the filters selected there were 33461 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 341 343 506.846042 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 60 61 5259.523809 $194602.3800 $37.0000
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Subtotal (Total Children Is Unduplicated) 397 404 5766.369851 $194602.3800 $33.7500
Screening, Eval, and Assessment, Class # 02
AACRS -92597GN AAC RE-EVAL BY LICENSED SLP 1 1 1.000000 $52.6300 $52.6300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 159 180 127.609476 $6189.0500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 26 27 23.983333 $1336.1100 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 14 14 12.488889 $293.4900 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 412 413 433.936507 $10197.5100 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 18 18 16.405556 $239.1900 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 57 57 39.555554 $929.5500 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 32 32 20.852054 $204.1400 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 9 9 9.000000 $88.1100 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 35 35 25.205555 $723.9000 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 16 16 15.055555 $673.8800 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 12 12 9.979301 $846.6600 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 2 2 1.252055 $63.9400 $51.0700
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 46 46 34.338888 $470.7800 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 38 38 54.499673 $1138.5000 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 32 33 35.683671 $1605.7700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 16 16 8.331279 $958.0800 $115.0000
BEHV -H2014BA Behavior Analysis - Technician 1 1 12.857143 $626.9100 $48.7600
EVAL -96111 DEVELOPMENTAL EVALUATION 24 26 33.287366 $1664.3700 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 200 202 328.138868 $16406.9500 $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 30 30 55.783333 $4183.7500 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 13 13 20.033333 $1502.5000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 17.000000 $1275.0000 $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 8 8 16.000000 $1200.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 14 14 14.047031 $1053.5300 $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 52 54 95.340411 $5291.3900 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 12 12 20.087671 $1114.8700 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 505 510 986.571227 $73992.8600 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 319 321 598.029749 $44852.2000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 194 194 383.714286 $28778.5700 $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 31 31 58.500000 $4387.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 176 179 318.361254 $23877.0600 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 720 733 1417.373684 $78664.2600 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 227 228 414.048860 $22979.6900 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 274 293 584.079647 $43805.9800 $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 -97803 NUTRITIONAL EVAL, FOLLOW-UP 7 7 17.419047 $870.9500 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 77 86 49.143292 $2508.7700 $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 12 12 10.244445 $522.9800 $51.0500
OCTH -97165TLGT OT EVAL LOW COMPLEXITY 2 2 11.917460 $608.3900 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 44 44 30.898633 $1577.3900 $51.0500
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 2 2 1.172222 $59.8400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 396 420 352.248901 $17982.3100 $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 57 59 32.286152 $1648.2200 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 37 38 27.286638 $1392.9900 $51.0500
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 2 2 2.000000 $102.1000 $51.0500
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 2 2 1.127778 $57.5700 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 249 274 158.802841 $8106.9100 $51.0500
SCREEN-T1023 SCREENING 38 38 38.155556 $1907.7800 $50.0000
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 4 4 3.134856 $47.0200 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 17 17 18.000000 $918.9000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 24 25 28.883332 $1474.4900 $51.0500
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.142466 $7.2700 $51.0600
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 2 2 0.555556 $28.3600 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 450 472 300.579422 $15344.5900 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 10 10 3.388887 $172.9900 $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 5 6 3.402739 $173.7100 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 79 89 86.840477 $4433.2100 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 124 134 115.677130 $5153.3900 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 1.241096 $55.2900 $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) 3399 5658 7720.632516 $460266.5500 $59.6200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 108 117 117.153437 $585767.0000 $5000.0000
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 2 2 3.900000 $195.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 62 63 69.354274 $3467.7200 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 22 22 62.620633 $4312.0500 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 66 67 74.254076 $17078.4400 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 1036 1317 1220.881386 $61044.3100 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 171 219 170.008354 $8500.4500 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 308 385 336.897401 $8422.4700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1701 1840 3081.045053 $154052.2900 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 97 108 204.526191 $10226.3000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 143 149 166.788887 $4169.7200 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1290 1446 2055.248819 $102762.4700 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 112 115 138.973021 $6948.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 77 120 127.994445 $3199.8600 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 533 600 949.376192 $47468.8200 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 59 60 92.203972 $4610.2100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 30 51 62.911112 $1572.7800 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1750 1836 2499.529783 $124976.5700 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 150 156 184.676988 $9233.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 153 157 185.598412 $4639.9600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 134 149 1445.862697 $36146.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 6327 6943 46845.176895 $2342259.9500 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 547 577 3082.879571 $154144.0400 $50.0000
INTR -T1013 INTERPRETER 185 207 663.886202 $33194.3100 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3245 3977 24179.601643 $241796.1900 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 988 1077 6525.073778 $466151.6700 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 32 32 164.498411 $11751.7700 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 202 213 1556.142858 $89011.4000 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 11 12 67.661906 $3870.2700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 18 18 62.895238 $4493.2300 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 66 68 447.582537 $31975.3200 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 944 1037 6155.918242 $439779.0600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 24 28 160.611905 $11474.1200 $71.4400
PHY -97110HM PT SESSION BY PT ASST 110 113 811.923815 $46409.5400 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 4 5 24.035714 $1373.8900 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 20 20 61.461904 $4390.8500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 66 70 282.701582 $20196.2100 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.911111 $59.2200 $65.0000
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 3 3 1.449315 $165.2200 $114.0000
SENS -V5050 IN EAR MONAURAL HEARING AID 2 2 0.219178 $49.9500 $227.9200
SENS -V5060 BEHIND EAR HEARING AID 8 8 8.200000 $1869.6000 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 7 8 7.333333 $3343.9800 $456.0000
SENS -V5264 EARMOLD 47 48 51.199774 $921.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1766 1938 12230.307057 $873733.7900 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 42 43 224.469044 $16036.0700 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 22.285715 $1274.7400 $57.2000
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 30 32 157.328570 $11239.5600 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 82 88 449.118249 $32085.0300 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 91 94 590.795236 $8200.2400 $13.8800
SPL -92508TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 11.771429 $163.3900 $13.8800
TRAV -TRAVS Travel by mile 1233 1749 104947.578373 $46701.6800 $0.4500
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Subtotal (Total Children Is Unduplicated) 9707 27399 223044.823718 $6096911.3900 $27.3300
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Total 33461 236531.826085 $6751780.3200 $28.5400
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Number of Children (Unduplicated) With at Least One Authorization 10692