Summary Report for FSPSAs Initiated During the Report Period Center: 01
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: 07-01-24 and 09-30-24 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5596 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 80 82 83.078579 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 80 82 83.078579 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 22 23.916569 $1159.9600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.966667 $121.3700 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 10 10 21.571429 $327.6700 $15.1900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.571429 $66.9600 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $15.8400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $31.8100 $31.8100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $49.5900 $49.5900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $15.1900 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 14.000000 $323.9600 $23.1400
EXIT -EXIT COS Exit 126 128 94.087869 $4704.3900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GNTSGT F/U PHYC 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
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1917.4400 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 4 8.000000 $479.3600 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 65 65 130.000000 $10527.4000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 39.000000 $3158.2200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 24 24 48.000000 $3887.0400 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 12 22.000000 $1781.5600 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 27 27 54.000000 $4372.9200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 8 8 14.000000 $1133.7200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 309 320 639.000000 $38288.8800 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 91 92 185.071429 $11089.4800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 267 303 609.714286 $49374.6600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 68 82 163.500000 $13240.2300 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.172603 $68.1400 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 3 4.000000 $232.4400 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 5 5 5.000000 $290.5500 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $116.2200 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.142857 $473.1800 $58.1100
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Subtotal (Total Children Is Unduplicated) 664 1178 2156.715138 $149243.2100 $69.2000
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 19 20.922505 $104613.0000 $5000.0200
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 285 320 345.249886 $17262.5000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 45 49 37.789044 $1889.4400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 26 26 25.219407 $630.4900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 192 204 339.692057 $16984.5700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 12 14 10.642856 $532.1400 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 0.350000 $8.7500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 71 73 113.011107 $5650.5400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 2.133333 $106.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 3 4.666667 $116.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 68 69 127.866665 $6393.3300 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 2 2 4.300000 $215.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.700000 $17.5000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 116 118 189.488091 $9474.3800 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 6 8 3.233333 $161.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.683333 $67.0800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 688 736 4765.290529 $257325.7200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 96 99 613.004766 $33102.2500 $54.0000
INTR -T1013 INTERPRETER 201 276 490.611906 $24530.6000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 821 1058 6245.438152 $74945.2600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 27 29 192.395239 $15645.5900 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 4.533333 $368.6500 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 9.857143 $801.5800 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 1.714286 $139.4100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 44 45 260.471431 $21181.5500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 12 13 113.419049 $9223.2300 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 5.533333 $449.9700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 45 47 266.395241 $21663.2500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 8 8 54.095238 $4399.0100 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 4 4 15.000001 $976.7900 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 3.857143 $251.1700 $65.1200
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 11.714286 $184.6200 $15.7600
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 2.000000 $200.0000 $100.0000
TRAV -TRAVS Travel by mile 838 1102 6264.095295 $2787.5300 $0.4500
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Subtotal (Total Children Is Unduplicated) 974 4336 20548.374655 $632531.5000 $30.7800
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Total 5596 22788.168372 $781774.7100 $34.3100
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Number of Children (Unduplicated) With at Least One Authorization 1229