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: 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 1275 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 42 19.933330 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 42 42 19.933330 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.000000 $61.7100 $61.7100
OCTH -97165 OT EVAL LOW COMPLEXITY 1 1 0.111111 $6.4600 $58.1000
OCTH -97166TL OT EVAL MODERATE COMPLEXITY 1 1 0.055556 $3.2300 $58.1600
OCTH -97167TL OT EVAL HIGH COMPLEXITY 20 21 5.088888 $295.7100 $58.1100
PSTH -97161 PT EVAL LOW COMPLEXITY 1 1 0.111111 $6.4600 $58.1000
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.100000 $5.8100 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 21 21 4.700001 $273.1200 $58.1100
SPCH -92521 EVAL OF SPEECH FLUENCY 1 1 0.111111 $6.4600 $58.1000
SPCH -92521TL EVAL OF SPEECH FLUENCY 27 29 7.805556 $453.5800 $58.1100
SPCH -92521TLGT EVAL OF SPEECH FLUENCY 1 1 0.205556 $11.9500 $58.1200
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.166667 $9.6900 $58.1200
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 4.285714 $249.0400 $58.1100
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Subtotal (Total Children Is Unduplicated) 53 80 23.741271 $1383.2100 $58.2600
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 20 64 14.283337 $714.1900 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 1 0.038889 $1.9500 $50.0100
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 2.077777 $103.8900 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 3.033333 $151.6700 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 0.100000 $5.0000 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 75 88 457.428568 $12350.5700 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 407 415 2875.714280 $155288.5900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 3 3 13.714286 $740.5700 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 402 419 2868.617456 $34423.4100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 10.142857 $824.8200 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 44 50 274.928570 $22357.2000 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 2 2 10.571429 $859.6700 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 34 37 169.353968 $13771.8400 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 56 64 335.196825 $27258.2300 $81.3200
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Subtotal (Total Children Is Unduplicated) 501 1153 7037.201575 $269314.8200 $38.2700
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Total 1275 7080.876176 $270698.0300 $38.2300
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Number of Children (Unduplicated) With at Least One Authorization 543