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: 10-01-25 and 12-31-25 Date of Report: 01-07-26 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 4998 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 69 70 60.511905 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 69 70 60.511905 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 13 14 11.732877 $569.0500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 9.900000 $610.9300 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 12 12 32.176190 $488.7500 $15.1900
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 1 1 1.000000 $21.4600 $21.4600
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 2 2 2.000000 $52.0800 $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 5.000000 $121.4000 $24.2800
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 2 2 2.000000 $15.8400 $7.9200
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 1 1 1.000000 $31.8100 $31.8100
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 1 1 1.000000 $15.1900 $15.1900
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 7 7 12.571429 $290.9000 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 1.000000 $78.2500 $78.2500
EXIT -EXIT COS Exit 143 146 123.191259 $6159.5600 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 8 15 30.000000 $2250.0000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 6 6 12.000000 $971.7600 $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 -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 2 2 4.000000 $323.9200 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 12 12 24.000000 $1438.0800 $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 17 26 44.021916 $3564.9000 $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 78 87 174.000000 $14090.5200 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 17 20 36.500000 $2955.7700 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 15 16 32.000000 $2591.3600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 6 6 11.500000 $931.2700 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 35 35 70.000000 $5668.6000 $80.9800
IPDEI -T1024GPUKGT INITIAL PSYCH AND DEV EVAL BY PT 11 12 22.500000 $1822.0500 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 235 249 497.000000 $29780.2400 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 116 137 263.005479 $15759.2900 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 201 243 484.000000 $39194.3200 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 100 139 284.362622 $23027.6800 $80.9800
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 1.000000 $58.1100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 3 3 3.000000 $174.3300 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 7 7 8.000000 $464.8800 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 28.209524 $1639.2500 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 9.142857 $531.2900 $58.1100
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Subtotal (Total Children Is Unduplicated) 668 1228 2261.814153 $157068.6400 $69.4400
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.054795 $30274.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 245 253 274.152447 $13707.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 62 65 54.117581 $2705.8700 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 36 36 32.828931 $820.7300 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 128 142 256.147096 $12807.3600 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 17 19 30.333332 $1516.6600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 6 6 12.766667 $319.1700 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 28 28 66.424605 $3321.2400 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 9 9 16.799999 $840.0000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 3 3 10.100000 $252.5000 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 42 42 64.389956 $3219.5100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 3 3 -0.100000 $-5.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 2.933333 $73.3300 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 63 63 102.668252 $5133.4100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 6 6 9.433333 $471.6700 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 5 28.823809 $720.6000 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 1 1 9.000000 $450.0000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 621 656 4497.009467 $242838.6500 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 93 98 683.028561 $36883.5700 $54.0000
INTR -T1013 INTERPRETER 221 305 470.588094 $23529.4200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 742 905 5606.937507 $67283.2800 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 14 14 82.614286 $6718.1900 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 35 36 223.009521 $18135.1200 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 1 1 8.000000 $650.5600 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 12.857143 $1045.5400 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 36 36 74.457140 $6054.8600 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 17.666667 $1436.6600 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 1 1 9.285714 $755.1100 $81.3200
TRAV -TRAVS Travel by mile 761 954 5732.385125 $2550.9100 $0.4400
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Subtotal (Total Children Is Unduplicated) 932 3700 18394.713361 $484510.5100 $26.3400
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Total 4998 20717.039419 $641579.1500 $30.9700
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Number of Children (Unduplicated) With at Least One Authorization 1203