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: 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 5434 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 65 67 111.762699 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 65 67 111.762699 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 24 24 25.167124 $1220.6000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.000000 $123.4200 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 9 9 14.000000 $212.6600 $15.1900
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 11.142857 $290.1600 $26.0400
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 1 1 1.000000 $7.9200 $7.9200
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 7.285714 $168.5900 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 10.857143 $849.5700 $78.2500
EXIT -EXIT COS Exit 84 90 81.038454 $4051.9300 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 13 26.000000 $1950.0000 $75.0000
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 2.000000 $111.0000 $55.5000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 4 4 8.000000 $647.8400 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 10 11 21.500000 $1288.2800 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 4 4 7.500000 $607.3500 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 68 76 150.000000 $12147.0000 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 21 21 35.500000 $2874.7900 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 22 23 45.000000 $3644.1000 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 12 12 22.500000 $1822.0500 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 34 34 68.000000 $5506.6400 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 13 13 24.500000 $1984.0100 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 288 317 630.500000 $37779.5600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 96 99 190.000000 $11384.8000 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 229 259 516.000000 $41785.6800 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 70 83 161.000000 $13037.7800 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 5.000000 $290.5500 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 2 2 2.000000 $116.2200 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 2 2 1.016438 $59.0600 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 4 5 6.000000 $348.6600 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 1 1 0.082192 $4.7800 $58.1200
SPCH -92521 EVAL OF SPEECH FLUENCY 4 4 4.000000 $232.4400 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $58.1100
SPCH -92522TLGT EVAL OF SPCH SOUND PROD 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 4.285714 $249.0400 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 630 1134 2095.875636 $145647.0100 $69.4900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 22 22 30.046053 $150230.5000 $5000.0100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 272 297 318.273942 $15913.6900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 52 60 51.282879 $2564.1400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 36 37 33.841194 $846.0300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 177 199 372.484917 $18624.2300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 8 10 8.649998 $432.4900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 5.422222 $135.5600 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 67 72 139.676189 $6983.8100 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 5 5 10.966666 $548.3300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 4 5 5.616667 $140.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 59 102.100000 $5105.0000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 3 3 3.400000 $170.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 4.766666 $119.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 99 103 178.097617 $8904.8700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 3 3 2.933333 $146.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 2.888889 $72.2200 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 2.428571 $121.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 641 709 4416.664263 $238499.8900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 106 116 740.490472 $39986.4700 $54.0000
INTR -T1013 INTERPRETER 189 241 434.000001 $21700.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 774 1035 6027.249178 $72326.9900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 22 24 143.385715 $11660.1200 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 5 5 28.819047 $2343.5600 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 3.428571 $278.8100 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 42 45 251.557143 $20456.6500 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 9 9 40.857143 $3322.5000 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 0.666667 $54.2200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 42 44 237.119047 $19282.5200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 9 9 54.895237 $4464.0800 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 5 5 32.285714 $2102.4400 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 10.285714 $669.8000 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 6.142857 $499.5400 $81.3200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 1 1 1.333333 $86.8200 $65.1200
TRAV -TRAVS Travel by mile 830 1101 6098.563465 $2713.8600 $0.4400
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1019 4233 19800.619370 $651506.8000 $32.9000
-------------------------------------------------------------------------------------------------------------------------------------
Total 5434 22008.257705 $797153.8100 $36.2200
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1356