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: 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 66 69 59.362700 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 66 69 59.362700 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 13 11.232877 $544.7900 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.000000 $246.8400 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 9 10 14.264286 $216.6700 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 3.133333 $67.2400 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 3.133333 $81.5900 $26.0400
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 5 5 7.990476 $194.0100 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 3 3 4.133333 $32.7400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 2 2 3.133333 $99.6700 $31.8100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 2.133333 $105.7900 $49.5900
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 2 2 3.133333 $47.5900 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 8 8 9.133333 $211.3400 $23.1400
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 2.733333 $150.0600 $54.9000
EXIT -EXIT COS Exit 95 101 87.255480 $4362.7700 $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 6 7 13.000000 $1052.7400 $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 284 315 625.791193 $37497.4100 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 115 122 236.000000 $14141.1200 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 263 317 628.291193 $50879.0200 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 85 100 198.000000 $16034.0400 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 9.571429 $556.1900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 1.000000 $58.1100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 1.857143 $107.9200 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 662 1258 2322.420741 $161993.2200 $69.7500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 8 10 8.463013 $42315.0000 $4999.9900
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 8.000000 $554.8000 $69.3500
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 232 251 253.982096 $12699.1100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 63 70 63.196807 $3159.8300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 34 35 31.569407 $789.2400 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 159 174 293.886512 $14694.3400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 27 32 50.229367 $2511.4800 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 11 11 14.899999 $372.5000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 43 44 62.683333 $3134.1700 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 10 10 17.933333 $896.6700 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 2 2 3.366667 $84.1700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 54 56 90.188892 $4509.4600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 10 10 16.783334 $839.1700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 3 3 6.200000 $155.0000 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 75 80 148.203175 $7410.1600 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 7 7 13.700001 $685.0100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 4.666666 $116.6700 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 2 10.142858 $507.1400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 699 739 4884.695307 $263773.4000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 103 115 677.223818 $36570.0700 $54.0000
INTR -T1013 INTERPRETER 226 277 456.185716 $22809.2800 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 834 1043 6165.280244 $73983.3200 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 19 104.876191 $8528.5200 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 3 3 6.133334 $498.7700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 34 35 233.480958 $18986.6600 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 4 4 18.000001 $1463.7600 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 8.857143 $720.2600 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 30 31 180.857147 $14707.3100 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 6.000000 $487.9200 $81.3200
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 1 1 1.000000 $65.1200 $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 1 1 11.142857 $906.1400 $81.3200
SPL -92508HA GROUP SPL SESSION PER CHILD 1 1 12.000000 $189.1200 $15.7600
TRAV -TRAVS Travel by mile 853 1089 6226.680244 $2770.8800 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 992 4163 20091.651277 $542135.3200 $26.9800
-------------------------------------------------------------------------------------------------------------------------------------
Total 5490 22473.434718 $704128.5400 $31.3300
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 1212