Summary Report for FSPSAs Initiated During the Report Period Center: 01
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 5492 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 62 64 34.477779 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 62 64 34.477779 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 20 19.495891 $945.5500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 3.571429 $220.3900 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 12 12 23.403968 $355.5100 $15.1900
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 5 5 5.000000 $39.6000 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 12.000000 $381.7200 $31.8100
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.000000 $23.1400 $23.1400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $54.9000 $54.9000
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 21 22 43.000000 $3482.1400 $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 289 319 649.214286 $38900.9200 $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 71 84 163.000000 $13199.7400 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 5 5 5.000000 $290.5500 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 2.571429 $149.4200 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.032877 $118.1300 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 7.000000 $406.7700 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 2.000000 $116.2200 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 11.438096 $664.6700 $58.1100
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Subtotal (Total Children Is Unduplicated) 611 1131 2112.266430 $146128.8300 $69.1800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 17 17 15.983105 $79916.0000 $5000.0300
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 1.000000 $69.3500 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 272 297 317.807275 $15890.3600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 52 60 51.282879 $2564.1400 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 37 38 34.607861 $865.2000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 161 184 357.070634 $17853.5300 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 23 27 40.499998 $2024.9900 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 5 5 6.666667 $166.6700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 56 62 90.755550 $4537.7500 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 13 13 29.471428 $1473.5700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 5 5 5.316667 $132.9200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 59 60 110.214287 $5510.7200 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 7 7 9.600001 $480.0100 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.266667 $6.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 85 89 147.876988 $7393.8700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 13 13 25.595236 $1279.7600 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 5 5 7.600000 $190.0000 $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 693 766 4685.090544 $252994.7900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 79 92 495.047624 $26732.5700 $54.0000
INTR -T1013 INTERPRETER 187 242 412.214286 $20610.7200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 796 1049 5888.618331 $70663.3900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 20 111.790478 $9090.7800 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 2.657143 $216.0800 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 2 2 7.971429 $648.2300 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 0.428571 $34.8500 $81.3300
PHY -97110 PT SESSION BY LICENSED PT 41 45 248.014290 $20168.5100 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 6 6 62.285715 $5065.0700 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 2 2 13.285715 $1080.3900 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 3.866667 $314.4400 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 40 42 232.714290 $18924.2900 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 7 7 25.638097 $2084.8900 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 7 7 37.428572 $2437.3400 $65.1200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 6 6 61.790476 $5024.8000 $81.3200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 2 3 5.476190 $356.6100 $65.1200
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 4.857143 $76.5500 $15.7600
TRAN -TRAN *FAMILY TRANSPORTATION 1 1 4.142857 $414.2900 $100.0000
TRAV -TRAVS Travel by mile 822 1115 5976.284997 $2659.4500 $0.4500
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Subtotal (Total Children Is Unduplicated) 962 4297 19534.647229 $580306.5600 $29.7100
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Total 5492 21681.391438 $726435.3900 $33.5100
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Number of Children (Unduplicated) With at Least One Authorization 1159