Summary Report for FSPSAs Initiated During the Report Period Center: 03
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 671 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 51 51 27.844448 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 51 51 27.844448 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 7 5.044444 $244.6500 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.194444 $2.9500 $15.1900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 3.122222 $99.3200 $31.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.050000 $2.9100 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 22 25 17.338890 $1007.5700 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 19 19 11.227778 $652.4500 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 18 20 18.025396 $1047.4500 $58.1100
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Subtotal (Total Children Is Unduplicated) 62 77 55.003174 $3057.3000 $55.5800
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 8 7.224658 $36123.5000 $5000.0300
CONIF -CONIF CONSULT, ITDS FACE TO FACE 6 7 6.688889 $334.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 35 44 60.493654 $3024.7000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 21 27 31.566668 $1578.3400 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 33 39 53.411114 $2670.5700 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 234 328 1422.452395 $76812.3900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 29 40 155.552384 $12649.5500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 18 24 107.790478 $8765.5100 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 21 26 101.695239 $8269.8500 $81.3200
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Subtotal (Total Children Is Unduplicated) 300 543 1946.875479 $150228.8300 $77.1600
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Total 671 2029.723101 $153286.1300 $75.5200
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Number of Children (Unduplicated) With at Least One Authorization 352