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: 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 1410 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 1 1 0.400000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.400000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 23 19.911480 $965.7000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.076712 $128.1500 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.061111 $0.9300 $15.1900
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 58 58 103.032874 $8343.6100 $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 15 16 32.000000 $2591.3600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 62 62 109.032874 $6533.2600 $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 2 2 0.219179 $12.7400 $58.1200
OCTH -97165 OT EVAL LOW COMPLEXITY 19 20 13.426485 $780.2200 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.266667 $15.5000 $58.1200
OCTH -97166 OT EVAL MODERATE COMPLEXITY 9 9 4.696727 $272.9300 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 1.167123 $67.8200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.030137 $1.7500 $58.0400
PSTH -97161 PT EVAL LOW COMPLEXITY 11 11 6.561110 $381.2600 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 1.219179 $70.8500 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 25 25 14.119178 $820.4700 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 7 9 2.737823 $159.0900 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 3 3 0.520396 $30.2400 $58.1100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 0.093151 $5.4200 $58.1400
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $232.4400 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.300000 $17.4300 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 4.000000 $232.4400 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 11.142857 $647.5100 $58.1100
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Subtotal (Total Children Is Unduplicated) 180 395 586.626021 $42065.7000 $71.7100
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 24 24 25.113808 $125569.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 50 51 53.066006 $2653.2900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 11 11 13.250000 $662.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 154 168 284.052373 $14202.5800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 3.933334 $196.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.100000 $27.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 87 88 130.119045 $6505.9400 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 0.933333 $23.3300 $25.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.666667 $16.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 139 139 218.466660 $10923.3000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 2.933333 $73.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 152 156 1071.195254 $57844.5100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 14 14 119.285716 $6441.4300 $54.0000
INTR -T1013 INTERPRETER 20 30 57.700487 $2885.0300 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 41 88 346.090478 $4153.0800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 43 244.257150 $19862.9500 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 0.266667 $21.6900 $81.3300
PHY -97110 PT SESSION BY LICENSED PT 15 15 97.615874 $7938.1300 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 24.285715 $1581.4800 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 51 52 312.044450 $25375.4300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 10.142857 $824.8200 $81.3200
TRAV -TRAVS Travel by mile 52 120 20327.240575 $9045.6200 $0.4500
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Subtotal (Total Children Is Unduplicated) 230 1014 23343.759782 $296828.3000 $12.7200
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Total 1410 23930.785803 $338894.0000 $14.1600
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Number of Children (Unduplicated) With at Least One Authorization 264