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: 01-01-25 and 03-31-25 Date of Report: 04-06-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1307 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 0.155556 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 1 1 0.155556 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 23 24 20.940683 $1015.6200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 2.169863 $133.9000 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.388889 $5.9100 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
EXIT -EXIT COS Exit 7 7 4.008220 $200.4100 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 5 5 10.000000 $809.8000 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $599.2000 $59.9200
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 69 70 101.598622 $8227.4900 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 19 19 37.000000 $2996.2600 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 32 35 67.000000 $5425.6600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 12 24.000000 $1943.5200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 95 96 149.098622 $8934.0100 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 30 30 59.000000 $3535.2800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 38 59 117.000000 $9474.6600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 4 5 10.000000 $809.8000 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 0.232877 $13.5300 $58.1200
OCTF -97168GT OT RE-EVAL EST PLAN CARE 1 1 0.189041 $10.9800 $58.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 20 20 14.975799 $870.2400 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 2.700000 $156.9000 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 8 8 3.778006 $219.5500 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.331507 $19.2600 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 9 9 5.563167 $323.2800 $58.1100
PSTH -97161GT PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 3 3 2.169863 $126.0900 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 2 2 0.199392 $11.5900 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 22 24 16.134020 $937.5600 $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 6.050630 $351.5900 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 5 5 4.232877 $245.9700 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.700000 $40.6800 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 8.857143 $514.6900 $58.1100
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Subtotal (Total Children Is Unduplicated) 245 469 692.319221 $48850.0700 $70.5600
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 25 26 51.768461 $258842.0000 $4999.9900
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.153425 $10.6400 $69.3400
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 29 31 29.029073 $1451.4600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 18 19 16.108334 $805.4200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 134 152 210.280956 $10514.0700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 1 1 1.533333 $76.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 1.966667 $49.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 78 82 116.400002 $5820.0100 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.066667 $51.6700 $25.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 2.066667 $51.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 122 125 177.166670 $8858.3500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 1.000000 $50.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.666667 $41.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 128 137 804.366659 $43435.8100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 12 12 59.714284 $3224.5800 $54.0000
INTR -T1013 INTERPRETER 25 35 84.142857 $4207.1400 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 26 48 174.009522 $2088.1100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 41 304.995236 $24802.2200 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 2.700000 $219.5600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 15 15 119.592857 $9725.3000 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 23.857143 $1553.5800 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 46 265.350978 $21578.3300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 3 4.857143 $394.9800 $81.3200
TRAV -TRAVS Travel by mile 29 54 5156.542859 $2294.6600 $0.4500
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Subtotal (Total Children Is Unduplicated) 214 837 7611.336460 $400147.0600 $52.5700
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Total 1307 8303.811237 $448997.1200 $54.0700
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Number of Children (Unduplicated) With at Least One Authorization 359