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: 01-01-23 and 03-31-23 Date of Report: 04-20-23 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 2214 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 4.541270 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 2 2 4.541270 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 17 18 7.494063 $363.4600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.106849 $6.0000 $56.1300
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.041096 $15.2800 $14.6800
EXIT -EXIT EXIT ASSESSMENT 11 11 19.428571 $971.4300 $50.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 2 2 4.000000 $300.0000 $75.0000
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $150.0000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 3.000000 $166.5000 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 78 79 156.505479 $11737.9100 $75.0000
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 30 30 59.500000 $4462.5000 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 36 38 76.000000 $5700.0000 $75.0000
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 19 19 37.500000 $2812.5000 $75.0000
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 1 1 2.000000 $150.0000 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 90 99 193.005479 $10711.8100 $55.5000
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 9 10 20.000000 $1110.0000 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 26 26 52.000000 $3900.0000 $75.0000
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 10 12 22.500000 $1687.5000 $75.0000
OCTH -97165 OT EVAL LOW COMPLEXITY 19 20 5.915525 $304.1200 $51.4100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 0.366667 $18.8500 $51.4100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 10 10 5.512709 $283.4100 $51.4100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 2 2 21.021527 $1080.7200 $51.4100
OCTH -97166TLGT OT EVAL MODERATE COMPLEXITY 2 2 10.450098 $537.2400 $51.4100
OCTH -97167 OT EVAL HIGH COMPLEXITY 3 3 1.454794 $74.7900 $51.4100
PSTF -97164 PT RE-EVAL EST PLAN CARE 2 2 0.650000 $33.4200 $51.4100
PSTH -97161 PT EVAL LOW COMPLEXITY 10 11 4.200001 $215.9300 $51.4100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.361111 $18.5600 $51.4100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 3 3 0.364384 $18.7300 $51.4100
PSTH -97163 PT EVAL HIGH COMPLEXITY 2 2 1.322222 $67.9700 $51.4100
SPCH -92521 EVAL OF SPEECH FLUENCY 26 28 22.155568 $1139.0200 $51.4100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.550000 $28.2800 $51.4100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.400000 $20.5600 $51.4100
SPCH -92522 EVAL OF SPCH SOUND PROD 2 2 1.232877 $63.3800 $51.4100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 1.164384 $59.8600 $51.4100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 9 10 6.412253 $329.6600 $51.4100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.106849 $56.9000 $51.4100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.283333 $12.7100 $44.8500
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.344444 $15.4500 $44.8500
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 28.142857 $1489.6000 $52.9300
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Subtotal (Total Children Is Unduplicated) 213 462 771.493140 $50264.0400 $65.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 20 21 49.667711 $248338.0000 $4999.9900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 35 35 35.395798 $1769.8000 $50.0000
COIFF -COIFFGT IFSP CONSULT,PROF,FACE TO FACE 3 3 5.005556 $250.2800 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 141 158 258.936078 $12946.8200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 79 82 127.350102 $6367.5300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.766667 $94.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 11 12 18.561905 $928.1000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 141 143 209.145605 $10457.3200 $50.0000
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 47.428571 $2371.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 128 131 836.971420 $41848.6000 $50.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 23 23 128.499999 $6425.0200 $50.0000
INTR -T1013 INTERPRETER 24 38 79.571429 $3978.5700 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 192 413 1487.572143 $14875.7300 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 45 46 348.628571 $25087.3100 $71.9600
PHY -97110 PT SESSION BY LICENSED PT 22 23 180.428570 $12983.6400 $71.9600
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 52 54 360.123805 $25914.5400 $71.9600
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 5 41.000000 $2950.3600 $71.9600
TRAV -TRAVS Travel by mile 235 557 91281.581873 $40620.3000 $0.4500
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Subtotal (Total Children Is Unduplicated) 259 1750 95499.635803 $458207.5000 $4.8000
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Total 2214 96275.670213 $508471.5500 $5.2800
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Number of Children (Unduplicated) With at Least One Authorization 288