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 287 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
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 20 14.488889 $702.7100 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 0.650000 $40.1100 $61.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 1.000000 $16.1500 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 1 1 2.000000 $48.5600 $24.2800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $49.5900 $49.5900
AUDE -V5010 ASSESSMENT FOR HEARING AID 1 1 0.622222 $28.2000 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.622222 $72.0600 $115.8100
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Subtotal (Total Children Is Unduplicated) 25 27 20.383333 $957.3800 $46.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 13 16.155555 $80777.5000 $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 20 24 82.052380 $4430.8300 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 9.071429 $489.8600 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 5 5 13.479365 $1096.1400 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 3 3 4.939682 $401.7000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 10.438096 $848.8300 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 2 6.071428 $493.7300 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 1 1 0.005556 $0.4600 $81.9700
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 3 4 5.166667 $420.1600 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 3 3 4.430158 $360.2600 $81.3200
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Subtotal (Total Children Is Unduplicated) 189 246 305.588886 $97243.1600 $318.2200
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Total 287 339.983330 $98200.5300 $288.8400
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Number of Children (Unduplicated) With at Least One Authorization 212