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: 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 1419 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 1.744444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 1.744444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 21 13.345890 $647.2800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 1.175342 $72.5300 $61.7100
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.123288 $5.5900 $45.3200
EXIT -EXIT COS Exit 7 7 7.000000 $350.0000 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 5 10.000000 $750.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 3 4.005479 $324.3700 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3300 $60.1600
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 57 57 101.032874 $8181.6500 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 10 10 20.000000 $1619.6000 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 21 21 40.500000 $3279.6900 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 16 17 34.000000 $2753.3200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 61 61 107.032874 $6413.4200 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 14 14 28.000000 $1677.7600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 40 56 109.500000 $8867.3100 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 7 15 30.000000 $2429.4000 $80.9800
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.016438 $0.9500 $57.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 18 18 18.212577 $1058.3200 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 1.488889 $86.5200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 2.154186 $125.1800 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 0.087671 $5.1000 $58.1300
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.288889 $16.7900 $58.1100
PSTF -97164GT PT RE-EVAL EST PLAN CARE 1 1 0.087671 $5.1000 $58.1300
PSTH -97161 PT EVAL LOW COMPLEXITY 15 15 6.015754 $349.5800 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 2 2 1.488889 $86.5200 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 1.400000 $81.3500 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 27 29 14.930060 $867.5800 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 6 7 1.830822 $106.3900 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 0.172603 $10.0300 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 6.238889 $362.5400 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.244444 $14.2000 $58.1000
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.366667 $21.3100 $58.1200
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Subtotal (Total Children Is Unduplicated) 198 391 565.745675 $40909.6100 $72.3100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 22 59.275517 $296377.5000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 49 50 52.742195 $2637.1000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 10 12.250000 $612.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 145 170 272.099991 $13604.9600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 5.499999 $275.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 79 85 156.914280 $7845.7000 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 1.800000 $90.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.133333 $53.3300 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.633333 $81.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.400000 $60.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 139 145 288.047613 $14402.3500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.233333 $111.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 10.376190 $259.4100 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 139 150 941.547617 $50843.6100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 17 18 122.142857 $6595.7100 $54.0000
INTR -T1013 INTERPRETER 20 29 51.414773 $2570.7500 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 53 96 290.519043 $3486.2300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 40 303.428569 $24674.8000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 21 21 162.285715 $13197.0600 $81.3200
PHY -97110HM PT SESSION BY PT ASST 4 4 37.857142 $2465.2600 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 50 52 339.539681 $27611.3700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 10.000000 $813.2000 $81.3200
TRAV -TRAVS Travel by mile 54 118 13021.340575 $5794.5000 $0.4500
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Subtotal (Total Children Is Unduplicated) 227 1026 16147.481756 $474463.6500 $29.3800
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Total 1419 16714.971875 $515373.2600 $30.8300
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Number of Children (Unduplicated) With at Least One Authorization 323