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 587 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 12 12 10.330593 $501.0300 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.133333 $8.2300 $61.6900
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
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
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 2 2 4.000000 $239.6800 $59.9200
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 1.000000 $58.1100 $58.1100
OCTH -97166 OT EVAL MODERATE COMPLEXITY 1 1 0.205556 $11.9500 $58.1200
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92521GT EVAL OF SPEECH FLUENCY 1 1 0.205556 $11.9500 $58.1200
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Subtotal (Total Children Is Unduplicated) 23 30 27.511111 $1553.5500 $56.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.133333 $5666.5000 $4999.8500
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 92 95 152.433331 $7621.6600 $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 140 142 225.714285 $11285.7100 $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 6 6 46.285715 $2499.4300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 26.142857 $1411.7200 $54.0000
INTR -T1013 INTERPRETER 20 30 56.500000 $2825.0000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 1 1 8.857143 $106.2900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 14.285714 $1161.7100 $81.3200
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 2 2 14.714285 $1196.5700 $81.3200
TRAV -TRAVS Travel by mile 5 10 506.000000 $225.1700 $0.4500
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Subtotal (Total Children Is Unduplicated) 213 554 1441.033382 $53199.2500 $36.9200
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Total 587 1477.017509 $54752.8000 $37.0700
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Number of Children (Unduplicated) With at Least One Authorization 224