Summary Report for FSPSAs Ending During the Report Period Center: 03
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: 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 651 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 52 53 42.747625 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 52 53 42.747625 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 7 9 5.477778 $265.6700 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.322222 $4.8900 $15.1900
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 4 4 3.411111 $108.5100 $31.8100
OCTH -97165 OT EVAL LOW COMPLEXITY 2 2 0.455556 $26.4700 $58.1200
OCTH -97167 OT EVAL HIGH COMPLEXITY 37 41 23.499999 $1365.5800 $58.1100
PSTH -97163 PT EVAL HIGH COMPLEXITY 16 18 9.849998 $572.3700 $58.1100
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 28 28 18.545240 $1077.6800 $58.1100
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Subtotal (Total Children Is Unduplicated) 82 103 61.561904 $3421.1800 $55.5700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 7 7 6.002740 $30013.5000 $4999.9700
CONIF -CONIF CONSULT, ITDS FACE TO FACE 8 8 7.855555 $392.7800 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 44 48 52.060316 $2603.0100 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 20 23 28.977777 $1448.8900 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 34 35 47.311111 $2365.5600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 260 286 1408.061899 $76035.3900 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 38 44 183.244445 $14901.4500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 16 18 62.085714 $5048.8200 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 26 26 127.366666 $10357.4600 $81.3200
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Subtotal (Total Children Is Unduplicated) 338 495 1922.966223 $143166.8400 $74.4500
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Total 651 2027.275752 $146588.0200 $72.3100
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Number of Children (Unduplicated) With at Least One Authorization 391