Summary Report for FSPSAs Ending During the Report Period Center: 02
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 1435 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 5 5 9.852380 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 5 5 9.852380 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 30 30 26.775005 $1298.6000 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.283333 $4.3000 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
EXIT -EXIT COS Exit 1 1 0.002740 $0.1400 $49.2700
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 2 2 2.005479 $162.4100 $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 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3300 $60.1600
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 56 58 89.071227 $7213.0100 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 14 14 27.500000 $2226.9500 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 36 38 74.500000 $6033.0100 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 83 92 156.571227 $9381.7600 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 31 32 63.500000 $3804.9200 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 57 74 147.000000 $11904.0600 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 20 28 56.000000 $4534.8800 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.197260 $11.4700 $58.1200
OCTH -97165 OT EVAL LOW COMPLEXITY 25 25 13.003294 $755.6200 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 13 13 6.837517 $397.3300 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 4 4 1.843607 $107.1300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 2 2 0.688889 $40.0300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.101370 $5.8900 $58.1300
PSTH -97161 PT EVAL LOW COMPLEXITY 19 19 8.448707 $490.9600 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 3.199163 $185.9100 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.505556 $29.3800 $58.1200
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.394444 $22.9200 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 26 26 14.466697 $840.6500 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 2 2 0.244444 $14.2000 $58.1000
SPCH -92522 EVAL OF SPCH SOUND PROD 4 4 0.624656 $36.3000 $58.1100
SPCH -92522GT EVAL OF SPCH SOUND PROD 4 4 1.727549 $100.3900 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 1.082192 $62.8900 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.106849 $64.3200 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 2 2 1.033333 $60.0500 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.450000 $26.1500 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 1.571429 $91.3100 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.388889 $22.6000 $58.1100
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Subtotal (Total Children Is Unduplicated) 250 510 734.130335 $52373.3700 $71.3400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 29 29 86.593324 $432966.5000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 38 39 39.757870 $1987.8800 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 10 15.500000 $775.0000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 158 180 301.285715 $15064.2800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 4 4.333333 $216.6700 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 1 1 2.333333 $58.3300 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 96 100 149.319047 $7465.9500 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 4 2.233332 $111.6600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.366667 $18.3400 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 3.033333 $75.8300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 132 136 198.795240 $9939.7700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.366667 $18.3400 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 2 2.766667 $69.1700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 154 166 1054.219040 $56927.8300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 18 20 120.285712 $6495.4300 $54.0000
INTR -T1013 INTERPRETER 22 34 72.535714 $3626.7900 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 8 10 24.647620 $295.7700 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 58 59 380.852379 $30970.9200 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 10.857143 $882.9000 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 1 1 5.285714 $429.8300 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 33 33 192.000001 $15613.4300 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 11.571429 $940.9900 $81.3200
PHY -97110HM PT SESSION BY PT ASST 3 3 19.428571 $1265.1900 $65.1200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 51 52 319.857141 $26010.7600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 22.999999 $1870.3600 $81.3200
TRAV -TRAVS Travel by mile 15 26 2062.142856 $917.6500 $0.4500
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Subtotal (Total Children Is Unduplicated) 246 920 5103.367847 $615015.5600 $120.5100
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Total 1435 5847.350562 $667388.9200 $114.1400
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Number of Children (Unduplicated) With at Least One Authorization 396