Summary Report for FSPSAs Initiated During the Report Period Center: 55
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 700 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 26 26 656.455556 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 560.777778 $25616.3300 $45.6800
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 29 29 1217.233334 $25616.3300 $21.0400
Screening, Eval, and Assessment, Class # 02
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 1.000000 $45.3200 $45.3200
EXIT -EXIT COS Exit 1 2 2.000000 $100.0000 $50.0000
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 1 1 2.000000 $161.9600 $80.9800
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 4 4 8.000000 $479.3600 $59.9200
IPDEF -T1024TSTL F/U PSYCH AND DEV EVAL BY EI PROF 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 21 21 42.000000 $3401.1600 $80.9800
IPDEI -T1024GNUKGT INITIAL PSYCH AND DEV EVAL BY SPAT 1 1 2.000000 $161.9600 $80.9800
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 7 7 14.000000 $1133.7200 $80.9800
IPDEI -T1024GOUKGT INITIAL PSYCH AND DEV EVAL BY OT 2 2 4.000000 $323.9200 $80.9800
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 9 9 18.000000 $1457.6400 $80.9800
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 5 5 10.000000 $599.2000 $59.9200
IPDEI -T1024HNUKGT INITIAL PSYCH AND DEV EVAL BY ITDS 3 3 6.000000 $359.5200 $59.9200
OCTF -97168 OT RE-EVAL EST PLAN CARE 3 4 0.365982 $21.2700 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 4 6 4.677778 $271.8300 $58.1100
PSTF -97164 PT RE-EVAL EST PLAN CARE 1 1 0.049315 $2.8600 $58.0900
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 0.377778 $5.7100 $15.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 1.000000 $58.1100 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 8 8 2.065981 $120.0500 $58.1100
SPCH -92523GT EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 1.000000 $58.1100 $58.1100
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 47 80 122.536834 $9085.6200 $74.1500
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 1 1 1.000000 $5000.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 6 7 6.011111 $300.5600 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 4 4 4.000000 $200.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 2 2 1.211111 $30.2800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 105 108 64.605554 $3230.2700 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 1.411111 $70.5600 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 76 79 86.085716 $2152.1500 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 52 91 66.738891 $3336.9600 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 27 51 61.216666 $1530.4200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 8 16 6.777776 $338.8800 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 8 16 10.166668 $254.1700 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 88 91 58.022218 $2901.0900 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 2 2 1.622222 $81.1100 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 70 73 87.261113 $2181.5300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 19 19 59.142856 $3193.7200 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 2 2 20.857143 $1126.2900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 6 6 51.176190 $4161.6500 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 4 4 28.285714 $1841.9600 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 2 2 8.428571 $685.4100 $81.3200
PHY -97110HM PT SESSION BY PT ASST 1 1 10.857143 $707.0100 $65.1200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 1.000000 $459.2200 $459.2200
SENS -V5264 EARMOLD 1 1 0.377778 $6.8500 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 10 10 61.142856 $4972.1300 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 1 1 9.285714 $755.1100 $81.3200
----------------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 188 591 707.684122 $39748.9400 $56.1700
-------------------------------------------------------------------------------------------------------------------------------------
Total 700 2047.454290 $74450.8900 $36.3600
-------------------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 230