Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 975 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 14 14 14.011111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 14 14 14.011111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 3 3 2.272222 $265.4600 $116.8300
AACIS -92597TL AAC INTIAL EVAL BY LICENSED SLP 4 4 4.000000 $467.3200 $116.8300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 22 22 18.488889 $896.7100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 2.144444 $132.3300 $61.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 2 2 1.061111 $17.1400 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 14 14 10.038890 $243.7500 $24.2800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $49.5900 $49.5900
AUDE -V5010 ASSESSMENT FOR HEARING AID 16 17 3.966669 $179.7800 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.622222 $72.0600 $115.8100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 0.316667 $18.4000 $58.1200
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Subtotal (Total Children Is Unduplicated) 62 71 43.911114 $2342.5400 $53.3500
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 5 5 3.144445 $150.7500 $47.9400
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 5 5 3.966667 $190.1600 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 17 20 22.799999 $113999.5000 $4999.9800
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 142 160 157.127777 $7856.3900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 15 16 15.394444 $769.7200 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 0.566667 $28.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 -8.214286 $-410.7100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 1 1 -12.857143 $-642.8600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 3 3 0.516667 $25.8400 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 302 333 1577.165098 $85166.8400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 25 27 116.090479 $6268.8700 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 41 43 91.838097 $7468.2500 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 4 4 26.571429 $2160.7900 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 5 5 25.776191 $1678.5400 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 10.857143 $707.0100 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 41 43 154.017461 $12524.7100 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 13 13 45.688889 $3715.4100 $81.3200
OCCT -97530TLHM OT SESSION BY OT ASST 7 8 27.309525 $1778.3900 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 29 30 73.523016 $5978.8800 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 1 1 0.714286 $58.0900 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 4 5 15.147618 $1231.8000 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 16.428571 $1335.9700 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 26 27 111.840477 $9094.8600 $81.3200
PHY -97110TLGP PT SESSION BY LICENSED PT 1 1 2.857143 $232.3400 $81.3200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.622222 $285.7300 $459.2000
SENS -V5264 EARMOLD 1 1 0.622222 $11.2800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 62 67 148.761906 $12097.3000 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 9 9 25.469842 $2071.2100 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 47 52 78.989683 $6423.4200 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 3 3 3.938095 $320.2500 $81.3200
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Subtotal (Total Children Is Unduplicated) 469 890 2736.674630 $282577.0700 $103.2600
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Total 975 2794.596855 $284919.6100 $101.9500
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Number of Children (Unduplicated) With at Least One Authorization 482