Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 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 1448 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 42 43 17.488887 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 43 17.488887 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.416667 $24.2100 $58.1100
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.050000 $2.9100 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 33 34 9.533333 $553.9800 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.416667 $24.2100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 23 24 6.800000 $395.1500 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 15 16 4.249999 $246.9600 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.061111 $3.5500 $58.1000
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.211111 $12.2700 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 5.428571 $315.4600 $58.1100
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Subtotal (Total Children Is Unduplicated) 47 80 27.167459 $1578.7000 $58.1100
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 3.000000 $694.8600 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 31 80 15.888898 $794.4900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.388889 $19.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 0.966666 $48.3300 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 1.155556 $57.7800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 1.633333 $81.6700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.100000 $5.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 94 117 645.142853 $17418.8700 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 425 454 2715.571400 $146640.9000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 22.000000 $1188.0000 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 423 460 2765.771401 $33189.2700 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 70 76 400.642851 $32580.2800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 7.428571 $604.0900 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 44 49 265.285709 $21573.0700 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 2 14.357143 $1167.5300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 61 71 284.285707 $23118.1300 $81.3200
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Subtotal (Total Children Is Unduplicated) 535 1325 7143.618977 $279181.7100 $39.0800
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Total 1448 7188.275323 $280760.4100 $39.0600
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Number of Children (Unduplicated) With at Least One Authorization 573