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: 01-01-25 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 1274 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 3 3 1.244444 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 1.244444 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 17 10.078996 $488.8300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $123.4200 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.111111 $1.6900 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
EXIT -EXIT COS Exit 5 5 2.008220 $100.4100 $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 68 69 99.598622 $8065.5300 $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 94 95 147.098622 $8814.1700 $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
OCTH -97165 OT EVAL LOW COMPLEXITY 22 23 22.393750 $1301.3000 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 3.230212 $187.7000 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 1.361111 $79.0900 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.013699 $0.8000 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 6 6 1.884779 $109.5300 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 2.909893 $169.0900 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.344444 $20.0100 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 22 23 11.291552 $656.1400 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 1.447412 $84.1100 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $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 3 3 2.013699 $117.0200 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 2.000000 $116.2200 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 3 3 0.744444 $43.2600 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 9.857143 $572.8000 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.122222 $7.1000 $58.1000
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Subtotal (Total Children Is Unduplicated) 221 454 666.509931 $47432.7900 $71.1700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 18 18 40.729094 $203645.5000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 34 35 43.617962 $2180.9000 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 18 19 16.108334 $805.4200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 150 163 267.071434 $13353.5900 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 3.833334 $191.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 93 95 154.847619 $7742.3800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 2.300000 $115.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 3 5.066667 $126.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 136 137 238.595238 $11929.7600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 3.300000 $165.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 1.333333 $33.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 155 157 1031.133343 $55681.1900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 10 10 57.857144 $3124.2900 $54.0000
INTR -T1013 INTERPRETER 24 33 68.000000 $3400.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 4 7 12.466666 $149.6000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 45 46 299.861910 $24384.7500 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 9.285714 $755.1200 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 12 12 73.571430 $5982.8300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 3 3 19.142857 $1556.7000 $81.3200
PHY -97110HM PT SESSION BY PT ASST 2 2 9.571429 $623.2900 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 41 42 224.857148 $18285.3600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 4 22.428572 $1823.8900 $81.3200
TRAV -TRAVS Travel by mile 12 23 1702.476191 $757.6000 $0.4500
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Subtotal (Total Children Is Unduplicated) 228 817 4307.455419 $356813.8400 $82.8400
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Total 1274 4975.209794 $404246.6300 $81.2500
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Number of Children (Unduplicated) With at Least One Authorization 307