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: 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 1362 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 3 3 8.473016 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 3 3 8.473016 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 14 14 11.448401 $555.2500 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 3 3 1.550000 $95.6500 $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 2.500000 $113.3000 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.133333 $15.4400 $115.7800
EXIT -EXIT COS Exit 8 8 6.502740 $325.1400 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 3.500000 $262.5000 $75.0000
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 3 3 6.000000 $359.5200 $59.9200
IPDEF -T1024TSGT F/U PHYC AND DEV EVAL BY ITDS 1 1 2.000000 $119.8400 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 5 5 10.000000 $809.8000 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 44 44 52.098622 $4218.9800 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 5 5 9.500000 $769.3100 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 32 32 62.000000 $5020.7600 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 18 18 36.000000 $2915.2800 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 101 108 178.598622 $10701.6500 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 40 42 83.000000 $4973.3600 $59.9200
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 65 77 154.000000 $12470.9200 $80.9800
IPDEI -T1024TLGT INITIAL PSYCH AND DEV EVAL BY EI PR 15 16 32.000000 $2591.3600 $80.9800
OCTF -97168 OT RE-EVAL EST PLAN CARE 2 2 0.216438 $12.5800 $58.1000
OCTH -97165 OT EVAL LOW COMPLEXITY 26 27 17.105785 $994.0200 $58.1100
OCTH -97165GT OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 7 7 3.740563 $217.3700 $58.1100
OCTH -97166GT OT EVAL MODERATE COMPLEXITY 3 3 1.788889 $103.9500 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 18 18 10.096424 $586.7000 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
PSTH -97162 PT EVAL MODERATE COMPLEXITY 6 6 5.480518 $318.4700 $58.1100
PSTH -97162GT PT EVAL MODERATE COMPLEXITY 1 1 0.083333 $4.8400 $58.0900
SPCH -92521 EVAL OF SPEECH FLUENCY 27 28 18.223516 $1058.9700 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.205556 $11.9500 $58.1200
SPCH -92521TL EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92522 EVAL OF SPCH SOUND PROD 3 3 0.421537 $24.4900 $58.1000
SPCH -92522GT EVAL OF SPCH SOUND PROD 2 2 1.100000 $63.9200 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.104110 $6.0500 $58.1000
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 3 3 3.000000 $174.3300 $58.1100
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 2 2 0.424125 $24.6400 $58.1100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.050000 $2.9100 $58.1100
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 2 2 4.571428 $265.6400 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.361111 $20.9800 $58.1100
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Subtotal (Total Children Is Unduplicated) 250 495 726.805051 $50748.5400 $69.8200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 11 11 15.276190 $76381.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 46 48 57.469104 $2873.4600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 11 12 15.733333 $786.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 160 181 287.561902 $14378.0800 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 2.285714 $114.2900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 93 96 154.733331 $7736.6600 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 0.750000 $37.5000 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 1 1 2.266667 $56.6700 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 8 13.633332 $681.6600 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 0.300000 $15.0000 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.066667 $76.6700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 141 143 228.014285 $11400.7100 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.300000 $15.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 2 2 5.066667 $126.6700 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 153 158 996.228572 $53796.3300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 28 31 183.571427 $9912.8700 $54.0000
INTR -T1013 INTERPRETER 20 31 58.500000 $2925.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 8.857143 $106.2900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 43 44 282.947616 $23009.3100 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 1 1 9.285714 $755.1100 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 11.000000 $894.5200 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 25 25 176.699998 $14369.2500 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 11.000000 $894.5200 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 10.571428 $859.6700 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 5.142857 $334.9100 $65.1200
SENS -V5050 IN EAR MONAURAL HEARING AID 1 1 0.133333 $30.6100 $229.5500
SENS -V5264 EARMOLD 1 1 0.400000 $7.2500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 43 45 269.428571 $21909.9200 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 2 2 3.857143 $313.6600 $81.3200
TRAV -TRAVS Travel by mile 5 10 506.000000 $225.1700 $0.4500
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Subtotal (Total Children Is Unduplicated) 231 864 3320.080994 $245024.3900 $73.8000
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Total 1362 4055.359061 $295772.9400 $72.9300
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Number of Children (Unduplicated) With at Least One Authorization 393