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 565 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 11 11 8.115754 $393.6200 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.377778 $23.3100 $61.7100
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
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 0.005479 $0.4500 $81.2900
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 1 1 0.005479 $0.3300 $60.1600
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 4.000000 $239.6800 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 2 3 6.000000 $485.8800 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 2 2 4.000000 $323.9200 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.272222 $15.8200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.272222 $15.8200 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 17 29 28.429452 $1879.0000 $66.0900
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 0.377778 $1889.0000 $5000.2900
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 50 52 66.638823 $3331.9300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 7 8 10.933333 $546.6700 $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 84 86 126.657143 $6332.8600 $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 130 131 203.104762 $10155.2400 $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 4 5 25.714286 $1388.5800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 6.857143 $370.2800 $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 2 2 11.142857 $906.1400 $81.3200
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 3 3 23.571429 $1916.8300 $81.3200
TRAV -TRAVS Travel by mile 10 20 1080.285714 $480.7300 $0.4500
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 201 534 1889.711041 $43914.5100 $23.2400
-------------------------------------------------------------------------------------------------------------------------------------
Total 565 1926.415096 $45793.5100 $23.7700
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 207