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: 04-01-25 and 06-30-25 Date of Report: 07-19-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 5490 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 63 66 44.488889 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 63 66 44.488889 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 19 21 15.764385 $764.5800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 5.000000 $308.5500 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 11 11 31.601586 $480.0300 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 3 3 2.800000 $60.0900 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 3 3 2.800000 $72.9100 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 2.000000 $32.3000 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 2 2 2.000000 $48.5600 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 4 4 3.800000 $30.1000 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 13.228571 $420.8000 $31.8100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 3 3 2.800000 $138.8500 $49.5900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 3 3 2.800000 $42.5300 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 6 6 5.800000 $134.2100 $23.1400
EXIT -EXIT COS Exit 94 100 86.255480 $4312.7700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 14 28.000000 $2100.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $971.7600 $80.9800
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024GOTSGT F/U PHYC AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 6.000000 $485.8800 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 21 22 44.000000 $2636.4800 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 18 22 44.000000 $3563.1200 $80.9800
IPDEF -T1024TSTLGT F/U PHYC AND DEV EVAL BY EI PROF 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 54 66 131.000000 $10608.3800 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 14 16 30.000000 $2429.4000 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 12 13 26.000000 $2105.4800 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 7 8 15.000000 $1214.7000 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 42 42 84.000000 $6802.3200 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 14 15 27.500000 $2226.9500 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 285 316 627.791193 $37617.2500 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 116 123 238.000000 $14260.9600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 262 315 624.291193 $50555.1000 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 86 101 200.000000 $16196.0000 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 4 4 4.000000 $232.4400 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 2.054795 $119.4000 $58.1100
PSTH -97161TLGT PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 9 9 9.000000 $522.9900 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 11.409524 $663.0100 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.142857 $8.3000 $58.1300
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Subtotal (Total Children Is Unduplicated) 687 1279 2359.839584 $163467.7400 $69.2700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 14 10.657534 $53287.5000 $4999.9800
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 0.194521 $45.0500 $231.6000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 236 258 263.015430 $13150.7800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 62 70 62.530140 $3126.4900 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 32 32 28.202740 $705.0700 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 169 177 314.557928 $15727.8500 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 16 16 26.252381 $1312.6200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 8 8 9.233333 $230.8300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 53 55 88.833335 $4441.6800 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 13 13 24.180952 $1209.0500 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 1.866666 $46.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 64 69 120.849999 $6042.5000 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 6 6 8.800000 $440.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 79 83 136.629361 $6831.4500 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 10 10 22.866666 $1143.3300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 9.399999 $235.0000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 2.571429 $128.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 666 706 4520.947580 $244131.2700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 98 116 637.880943 $34445.5800 $54.0000
INTR -T1013 INTERPRETER 226 275 461.933333 $23096.6800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 807 1035 5931.426933 $71177.1600 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 18 19 101.195239 $8229.2200 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 8.066667 $655.9800 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 8.142857 $662.1800 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.428571 $34.8500 $81.3300
PHY -97110 PT SESSION BY LICENSED PT 39 42 228.863489 $18611.2100 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 5 5 53.999999 $4391.2800 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 2.933333 $238.5400 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 2 2 3.961904 $322.1800 $81.3200
SENS -V5060 BEHIND EAR HEARING AID 1 1 0.389041 $89.3200 $229.5900
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 37 212.961907 $17318.0500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 13.295238 $1081.1700 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 13.000000 $846.5600 $65.1200
SPL -92507HMGT SPL THERAPY SESSION BY SLP ASST 1 1 0.142857 $9.3100 $65.1400
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 2 2 4.323810 $351.6100 $81.3200
SPL -92507TLGTHM SPL THERAPY SESSION BY SLP ASST 1 1 1.000000 $65.1200 $65.1200
TRAV -TRAVS Travel by mile 843 1074 6004.741221 $2672.1100 $0.4400
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Subtotal (Total Children Is Unduplicated) 1073 4145 19340.277336 $536533.8000 $27.7400
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Total 5490 21744.605809 $700001.5400 $32.1900
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Number of Children (Unduplicated) With at Least One Authorization 1447