Summary Report for FSPSAs Initiated During the Report Period Center: 02
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 1318 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 2 2 8.274603 $0.0000 $0.0000
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 2 2 8.274603 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 14 9.132269 $442.9200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 1.438889 $88.7900 $61.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 1.000000 $24.2800 $24.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.366667 $16.6200 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.377778 $43.7500 $115.8200
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 0.178082 $10.3500 $58.1200
OCTH -97165 OT EVAL LOW COMPLEXITY 26 26 15.780213 $917.0000 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 4 4 3.327017 $193.3300 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 4 4 1.516667 $88.1400 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 17 17 8.908980 $517.7100 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 4 4 4.444445 $258.2700 $58.1100
PSTH -97162TLGT PT EVAL MODERATE COMPLEXITY 1 1 0.394444 $22.9200 $58.1000
SPCH -92521 EVAL OF SPEECH FLUENCY 25 25 15.831811 $919.9900 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.272222 $15.8200 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 1 1 0.210959 $12.2600 $58.1200
SPCH -92522GT EVAL OF SPCH SOUND PROD 3 3 1.783333 $103.6300 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 2 2 1.167123 $67.8200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 4 4 4.000000 $232.4400 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.316667 $18.4000 $58.1200
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.472222 $27.4400 $58.1100
SPCH -92610GT EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.555556 $32.2900 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 11.285714 $655.8100 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.116667 $6.7800 $58.1300
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 214 477 730.033877 $52293.8000 $71.6300
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 12 19.424169 $97120.5000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 50 52 66.638823 $3331.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 10 11 16.433333 $821.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 149 170 243.185712 $12159.2800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 3 3 8.233333 $411.6700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 85 87 126.890476 $6344.5200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 7 8 4.033332 $201.6600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 2.633333 $131.6700 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 1 1 0.033333 $0.8300 $24.9800
CONSF -CONSF CONSULT, SLP, FACE TO FACE 131 132 203.338095 $10166.9000 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 2.633333 $131.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 3 3 3.200000 $80.0000 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 145 157 892.552394 $48197.8100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 24 24 153.785718 $8304.4200 $54.0000
INTR -T1013 INTERPRETER 22 34 66.964286 $3348.2200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 2 2 2.000000 $24.0000 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 40 40 203.038096 $16511.1100 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 2 2 15.142857 $1231.4200 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 0.142857 $11.6200 $81.3400
PHY -97110 PT SESSION BY LICENSED PT 22 22 92.114285 $7490.7800 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 0.142857 $11.6200 $81.3400
PHY -97110GT PT SESSION BY LICENSED PT 2 2 14.285714 $1161.7100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 2 2 30.142857 $1962.9100 $65.1200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.377778 $86.7500 $229.6200
SENS -V5264 EARMOLD 1 1 1.133333 $20.5500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 44 281.642860 $22903.2200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 39.000000 $3171.4900 $81.3200
TRAV -TRAVS Travel by mile 10 20 1080.285714 $480.7300 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 218 839 3569.428878 $245820.6100 $68.8700
-------------------------------------------------------------------------------------------------------------------------------------
Total 1318 4307.737358 $298114.4100 $69.2000
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 299