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 17795 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 314 316 384.750012 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 2 2 23.244444 $860.0400 $37.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 315 318 407.994456 $860.0400 $2.1100
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 136 155 109.199962 $5296.1900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.322222 $129.3700 $55.7100
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 4 4 3.172222 $74.5500 $23.5000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 30 30 37.441270 $879.8700 $23.5000
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 3 3 2.261111 $32.9700 $14.5800
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 4 4 3.055555 $71.8000 $23.5000
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 8 8 3.502054 $34.2800 $9.7900
AUDE -92568 ACOUSTIC REFLEX TESTING (MEMR) 1 1 1.000000 $9.7900 $9.7900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 7 7 3.855555 $110.7300 $28.7200
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 2.055555 $92.0000 $44.7600
AUDE -92585 AUD EVOKED RESPONSE (COMP) 3 3 2.207611 $187.3000 $84.8400
AUDE -92586 AUD EVOKED RESPONSE (LIMITED) 1 1 0.252055 $12.8700 $51.0800
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 7 7 3.855555 $52.8600 $13.7100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 12.448880 $260.0600 $20.8900
AUDE -V5010 ASSESSMENT FOR HEARING AID 10 10 14.491739 $652.1400 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 3 3 0.739955 $85.1000 $115.0100
BEHV -H2014BA Behavior Analysis - Technician 1 1 12.857143 $626.9100 $48.7600
EVAL -96111 DEVELOPMENTAL EVALUATION 23 25 32.287366 $1614.3700 $50.0000
EVAL -96111GT DEVELOPMENTAL EVALUATION 2 3 6.000000 $300.0000 $50.0000
EXIT -EXIT EXIT ASSESSMENT 198 200 324.138868 $16206.9500 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $600.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 3 3 4.011111 $300.8300 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $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 3 3 6.000000 $450.0000 $75.0000
IPDEF -T1024GPTSGT F/U PHYC AND DEV EVAL BY PT 3 3 2.016590 $151.2500 $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 9 11 20.005479 $1110.3100 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 3 4.005479 $222.3100 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 60 60 120.000000 $9000.0000 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 45 45 82.060275 $6154.5200 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 25 47.500000 $3562.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 8 8 14.566667 $1092.5000 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 7 7 13.500000 $1012.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 29 29 48.358904 $3626.9000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 100 101 198.642857 $11024.6800 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 48 48 80.436530 $4464.2100 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 34 36 71.142857 $5335.7200 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 1 1 2.000000 $150.0000 $75.0000
NURS -T1001 NURSING ASSESSMENT 1 1 0.142857 $7.1500 $50.0200
OCTF -97168 OT RE-EVAL EST PLAN CARE 9 10 4.033333 $205.9000 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 4.000000 $204.2000 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 3 3 1.816667 $92.7400 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 60 65 62.256895 $3178.2200 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 3 2.133333 $108.9100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $51.0500 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 7 4.700000 $239.9300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 36 42 27.602379 $1409.1000 $51.0500
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.244444 $3.6700 $15.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 6.000000 $306.3000 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.400000 $20.4200 $51.0500
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.200000 $10.2100 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 47 50 31.332537 $1599.5100 $51.0500
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.194444 $9.9200 $51.0400
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 19 20 18.388889 $938.7500 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 15 17 28.845236 $1285.0500 $44.5500
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.241096 $10.7400 $44.5500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 771 1100 1498.923537 $85120.1000 $56.7900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 31 32 31.916211 $159581.5000 $5000.0100
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 1 1 1.000000 $50.0000 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 13 13 16.750468 $837.5300 $50.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 3.527778 $242.9200 $68.8600
AUDE -V5160 DISPENSING FEE BINAURAL 11 11 7.622222 $1753.1100 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 941 1182 1056.449486 $52822.7000 $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 168 181 121.207225 $3030.2200 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1673 1805 3055.052991 $152752.7000 $50.0000
CONIF -CONIFGT CONSULT,ITDS,FACE TO FACE 97 108 204.526191 $10226.3000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 135 141 158.033331 $3950.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1269 1423 2036.443264 $101822.2000 $50.0000
CONOF -CONOFGT CONSULT,OT,FACE TO FACE 112 115 138.973021 $6948.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 75 118 126.911112 $3172.7800 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 524 588 938.187304 $46909.3800 $50.0000
CONPF -CONPFGT CONSULT,PT,FACE TO FACE 59 60 92.203972 $4610.2100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 25 45 50.061111 $1251.5300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1725 1810 2477.737718 $123886.9600 $50.0000
CONSF -CONSFGT CONSULT,SLP,FACE TO FACE 150 156 184.676988 $9233.8700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 145 149 175.726190 $4393.1600 $25.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 4 4 7.576985 $189.4300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 1450 1613 11140.523398 $557026.3700 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 45 50 328.701588 $16435.1000 $50.0000
INTR -T1013 INTERPRETER 163 182 618.712392 $30935.6200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3244 3974 24148.458786 $241484.7600 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 127 134 882.147616 $63020.6600 $71.4400
OCCT -97530GT OT SESSION BY LICENSED OT 4 4 28.190475 $2013.9300 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 18 18 121.785714 $6966.1500 $57.2000
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 0.642857 $36.7700 $57.2000
OCCT -97530TL OT SESSION BY LICENSED OT 2 2 9.142858 $653.1600 $71.4400
OCCT -97530TLGT OT SESSION BY LICENSED OT 7 7 147.333333 $10525.4900 $71.4400
PHY -97110 PT SESSION BY LICENSED PT 118 130 836.252379 $59741.8600 $71.4400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 4.138096 $295.6300 $71.4400
PHY -97110HM PT SESSION BY PT ASST 12 13 68.285714 $3903.2100 $57.1600
PHY -97110HMGT PT SESSION BY LICENSED PT ASST 1 1 2.285714 $130.6500 $57.1600
PHY -97110TL PT SESSION BY LICENSED PT 1 1 11.142857 $796.0500 $71.4400
PHY -97110TLGT PT SESSION BY LICENSED PT 8 8 39.182539 $2799.2100 $71.4400
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.911111 $59.2200 $65.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.333333 $151.9800 $455.9500
SENS -V5264 EARMOLD 4 4 3.422223 $61.6000 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 272 293 1888.721420 $134930.3400 $71.4400
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 8 9 35.923016 $2566.3500 $71.4400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 1.533333 $109.5400 $71.4400
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 6 6 35.504761 $2536.4600 $71.4400
SPL -92508HA GROUP SPL SESSION PER CHILD 12 12 77.999999 $1082.6400 $13.8800
TRAV -TRAVS Travel by mile 1232 1744 104890.292659 $46676.1900 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 6666 16377 156376.160093 $1881105.3400 $12.0300
-------------------------------------------------------------------------------------------------------------------------------------
Total 17795 158283.078086 $1967085.4900 $12.4300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 7174