Summary Report for FSPSAs Ending During the Report Period Center: 02
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: 10-01-23 and 12-31-23 Date of Report: 01-14-24 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2050 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 2 2 2.666667 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 2.666667 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 20 8.996727 $436.3400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.000000 $23.6700 $23.6700
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.115068 $16.3700 $14.6800
EXIT -EXIT COS Exit 4 4 2.750000 $137.5000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 7 7 10.000000 $750.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4100 $75.2900
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TLTSGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 1.505479 $83.5600 $55.5000
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $111.0000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 59 64 98.054790 $7354.1300 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 28 28 53.000000 $3975.0000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 25 26 49.500000 $3712.5000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 8 8 15.500000 $1162.5000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 61 68 109.554790 $6080.3000 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 34 34 65.500000 $3635.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 11 16 30.000000 $2250.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 12 15 30.000000 $2250.0000 $75.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.191781 $9.8600 $51.4100
OCTH -97165 OT EVAL LOW COMPLEXITY 18 18 6.707763 $344.8500 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.094444 $4.8500 $51.3900
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 3.692694 $189.8400 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 12.857143 $660.9800 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.136986 $7.0400 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 7 8 1.901065 $97.7400 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.134247 $6.9000 $51.3900
PSTH -97161 PT EVAL LOW COMPLEXITY 14 15 10.530821 $541.3900 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 7 7 1.914079 $98.4000 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 0.188889 $9.7100 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 16 16 3.760425 $193.3300 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.094444 $4.8500 $51.3900
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.079452 $4.0900 $51.4400
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 0.342466 $17.6000 $51.4000
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 0.347945 $17.8900 $51.4200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 6 6 5.109589 $262.6800 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.068493 $3.5200 $51.4200
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 0.123288 $6.3400 $51.4200
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 2 12.857142 $660.9900 $51.4100
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Subtotal (Total Children Is Unduplicated) 200 397 544.115489 $35439.9900 $65.1300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 21 29.887093 $149436.0000 $5000.0200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 32 34 32.341327 $1617.0700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 3.250000 $162.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 1 1 1.000000 $25.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 145 170 277.829360 $13891.4500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.533333 $76.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.633333 $65.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 86 90 141.711900 $7085.5800 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.133333 $28.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 9 9 10.633334 $531.6700 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 140 146 219.623802 $10981.1600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 3.000000 $75.0000 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 27.714286 $1385.7200 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 132 135 773.554762 $38677.7300 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 17 17 147.000000 $7350.0000 $50.0000
INTR -T1013 INTERPRETER 18 26 62.906913 $3145.3500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 182 390 1309.989603 $15719.8600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 46 47 297.807144 $21430.1800 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 3 3 22.857142 $1644.8000 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 22 24 158.272225 $11389.2400 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 1 1 0.428571 $30.8400 $71.9600
PHY -97110HM PT SESSION BY PT ASST 2 2 1.142858 $65.7800 $57.5600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 36 224.457145 $16151.9300 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 35.142856 $2528.8800 $71.9600
TRAV -TRAVS Travel by mile 222 484 76108.896612 $33868.4600 $0.4500
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Subtotal (Total Children Is Unduplicated) 247 1651 79894.746932 $337365.0300 $4.2200
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Total 2050 80441.529088 $372805.0200 $4.6300
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Number of Children (Unduplicated) With at Least One Authorization 318