Summary Report for FSPSAs Initiated During the Report Period Center: 02
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: 10-01-23 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 1711 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 3.077778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 3.077778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 19 11.009436 $533.9600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $56.1000 $56.1000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.666667 $10.5600 $15.8400
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 60 67 112.983361 $6270.5900 $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 2 2 0.109589 $5.6300 $51.4200
OCTH -97165 OT EVAL LOW COMPLEXITY 17 18 8.640183 $444.2000 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 4 4 3.416667 $175.6500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 5 5 1.074049 $55.2200 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 13.466927 $692.3400 $51.4100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.115068 $5.9200 $51.4200
OCTH -97167 OT EVAL HIGH COMPLEXITY 5 5 1.966286 $101.0900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.057534 $2.9600 $51.3800
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.150685 $7.7500 $51.4200
PSTH -97161 PT EVAL LOW COMPLEXITY 16 16 7.822907 $402.1800 $51.4100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 2.966667 $152.5200 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 8 8 1.992085 $102.4100 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 0.338889 $17.4200 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 25 25 21.080269 $1083.7400 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 4 4 3.416667 $175.6500 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 1.000000 $51.4100 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.169863 $8.7300 $51.4200
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.131507 $6.7600 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.115068 $5.9200 $51.4200
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $154.2300 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.172222 $8.8500 $51.4000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.038356 $1.9700 $51.4700
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 2 0.161644 $8.3100 $51.4300
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 3 18.857142 $969.4500 $51.4100
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Subtotal (Total Children Is Unduplicated) 186 404 577.235486 $37195.8800 $64.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 17 42.376267 $211881.0000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.666667 $46.2400 $69.3500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 1.866667 $129.4600 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.666667 $154.4200 $231.6300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 39 40 36.707994 $1835.4100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 3.250000 $162.5000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 3 3 4.066666 $101.6700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 131 147 275.119040 $13755.9100 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 90 90 159.828564 $7991.4000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 2 2 2.366666 $118.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.400000 $85.0000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 11.676516 $583.8300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.466667 $11.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 123 124 238.560309 $11927.9700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.100000 $77.5000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 124 128 907.904778 $45395.2000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 23 167.428576 $8371.4100 $50.0000
INTR -T1013 INTERPRETER 18 27 60.906913 $3045.3500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 115 229 1065.048343 $12780.5600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 48 49 373.200008 $26855.4300 $71.9600
OCCT -97530GT OT SESSION BY LICENSED OT 5 5 51.428571 $3700.8100 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 25 25 157.285719 $11318.2600 $71.9600
PHY -97110GT PT SESSION BY LICENSED PT 3 3 31.000000 $2230.7600 $71.9600
PHY -97110HM PT SESSION BY PT ASST 5 5 48.714287 $2803.9900 $57.5600
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.666667 $306.1600 $459.2400
SENS -V5264 EARMOLD 1 1 0.666667 $12.0900 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 41 41 306.571437 $22060.8400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 35.714285 $2570.0100 $71.9600
TRAV -TRAVS Travel by mile 138 323 63493.520417 $28254.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 210 1305 67486.175358 $418617.7600 $6.2000
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Total 1711 68066.488622 $455813.6400 $6.7000
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Number of Children (Unduplicated) With at Least One Authorization 243