Summary Report for FSPSAs Ending During the Report Period Center: 01
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 5759 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 71 72 80.033335 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 71 72 80.033335 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 21 22 21.685388 $1051.7500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 9 9 10.966667 $676.7600 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 15 15 25.732801 $390.8800 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 4.000000 $31.6800 $7.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 4.000000 $92.5600 $23.1400
AUDE -92602 REPROGRAM COCHLEAR IMPLT <7 1 1 7.600000 $461.5500 $60.7300
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.052055 $6.0300 $115.9100
EXIT -EXIT COS Exit 126 128 94.087869 $4704.3900 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 3 6 12.000000 $900.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GNTSGT F/U PHYC AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 16 16 32.000000 $1917.4400 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 3 4 8.000000 $479.3600 $59.9200
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 65 65 130.000000 $10527.4000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 20 20 39.000000 $3158.2200 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 23 23 46.000000 $3725.0800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 13 13 24.000000 $1943.5200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 27 27 54.000000 $4372.9200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 8 8 14.000000 $1133.7200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 308 319 637.000000 $38169.0400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 92 93 187.071429 $11209.3200 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 267 303 609.571429 $49363.0900 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 69 83 165.500000 $13402.1900 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.172603 $68.1400 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 2 3 3.000000 $174.3300 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 2 2 0.241096 $14.0100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.000000 $232.4400 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $174.3300 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.202740 $11.7800 $58.1000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 4 4 23.447619 $1362.5300 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.142857 $356.9600 $58.1100
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Subtotal (Total Children Is Unduplicated) 692 1197 2184.474553 $151248.4200 $69.2400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 21 24 25.433485 $127167.0000 $4999.9800
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $694.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 287 325 352.016552 $17600.8300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 47 51 42.255711 $2112.7700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 29 29 30.086074 $752.1500 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 175 184 348.121434 $17406.1000 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 21 22 31.680954 $1584.0600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 2 2 4.200000 $105.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 69 70 134.328570 $6716.4300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 7 7 12.233333 $611.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 1.466667 $36.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 78 79 133.077775 $6653.8800 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 7 7 6.200000 $310.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 6.166666 $154.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 106 112 196.671432 $9833.5900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 12 14 20.932541 $1046.6300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 8.399999 $210.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 677 718 4944.795220 $267019.0800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 138 144 949.599997 $51278.4300 $54.0000
INTR -T1013 INTERPRETER 206 272 472.526190 $23626.3200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 862 1102 6976.001558 $83712.0600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 23 172.461903 $14024.5900 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 -19.857143 $-1614.7800 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 2 2 3.571428 $290.4300 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 11.428571 $929.3700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 59 61 346.766668 $28199.0700 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 7 7 40.590475 $3300.8200 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 2 2 0.704762 $57.3100 $81.3100
SENS -V5014 *HEARING AID REPAIR BY MANUFACTURER 1 1 0.052055 $5.9800 $114.9100
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 59 61 413.061903 $33590.1900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 28.504762 $2318.0100 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 2.142857 $174.2600 $81.3200
SPL -92508HA GROUP SPL SESSION PER CHILD 2 2 6.428571 $101.3100 $15.7600
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 2.000000 $200.0000 $100.0000
TRAV -TRAVS Travel by mile 901 1148 7019.682511 $3123.7600 $0.4500
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Subtotal (Total Children Is Unduplicated) 1097 4490 22726.733481 $703331.9700 $30.9500
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Total 5759 24991.241369 $854580.3900 $34.2000
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Number of Children (Unduplicated) With at Least One Authorization 1468