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: 01-01-24 and 03-31-24 Date of Report: 04-04-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1350 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
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 20 14.897338 $722.5200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.071233 $4.3900 $61.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.128767 $5.8400 $45.3300
EXIT -EXIT COS Exit 1 1 1.000000 $50.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 5 9.000000 $675.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 47 49 78.054790 $6320.8900 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 13 14 27.500000 $2226.9500 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 46.000000 $3725.0800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 8 8 16.000000 $1295.6800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 54 56 92.054790 $5515.9400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 18 19 37.500000 $2247.0000 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 36 52 99.000000 $8017.0200 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 7 10 20.000000 $1619.6000 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.272222 $15.8200 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 20 20 23.942466 $1391.2900 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 1.033333 $60.0500 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 6 6 1.119711 $65.0700 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.164384 $9.5500 $58.1200
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.372222 $21.6300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.211111 $12.2700 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.164384 $9.5500 $58.1200
PSTH -97161 PT EVAL LOW COMPLEXITY 16 16 6.458220 $375.2900 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 1.033333 $60.0500 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.471689 $85.5200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 29 30 11.412632 $663.1900 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 1.272603 $73.9500 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.084932 $4.9300 $58.0900
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 7 7 5.450000 $316.7000 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.422222 $82.6400 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.127778 $7.4300 $58.1200
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Subtotal (Total Children Is Unduplicated) 170 361 503.220160 $36120.9800 $71.7800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 17 30.063948 $150320.0000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 46 47 50.395057 $2519.7300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 6 7 5.104166 $255.2100 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 156 173 273.052377 $13652.6000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 4.300000 $215.0000 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 2.000000 $50.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 76 77 114.380952 $5719.0500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 2.466666 $61.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 4.500000 $225.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.900000 $72.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 141 141 209.042852 $10452.1200 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 1.566667 $78.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 5.833333 $145.8300 $25.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 1 1 2.428571 $121.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 152 155 971.638117 $52468.3800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 15 15 92.285715 $4983.4200 $54.0000
INTR -T1013 INTERPRETER 12 20 34.293934 $1714.7000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 66 122 382.090479 $4585.0900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 38 229.428572 $18657.1200 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 9.571429 $778.3500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 23 23 164.857143 $13406.1600 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 6.000000 $487.9200 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 17.428571 $1134.9500 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 51 52 300.026985 $24398.1600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 15.000000 $1219.8000 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 5.142857 $418.2200 $81.3200
TRAV -TRAVS Travel by mile 32 79 8584.938097 $3820.3000 $0.4500
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Subtotal (Total Children Is Unduplicated) 223 989 11520.736488 $311961.0100 $27.0800
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Total 1350 12023.956648 $348081.9800 $28.9500
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Number of Children (Unduplicated) With at Least One Authorization 255