Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 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 995 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 19 19 12.200000 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 19 19 12.200000 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 1 1 0.466667 $22.6400 $48.5000
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.266667 $15.5000 $58.1200
OCTH -97167GT OT EVAL HIGH COMPLEXITY 1 1 0.316667 $18.4000 $58.1200
OCTH -97167TL OT EVAL HIGH COMPLEXITY 27 28 10.033330 $583.0200 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 13 14 3.644442 $211.7600 $58.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 17 18 6.572220 $381.9000 $58.1100
SPCH -92522TL EVAL OF SPCH SOUND PROD 1 1 0.422222 $24.5300 $58.1100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.116667 $6.7800 $58.1300
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 6.000000 $348.6600 $58.1100
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Subtotal (Total Children Is Unduplicated) 43 66 27.838882 $1613.1900 $57.9500
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 1 1 1.000000 $231.6200 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 26 68 22.872224 $1143.6200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 1 3 1.416666 $70.8300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2 2 1.811111 $90.5600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 1.811111 $90.5600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 64 71 581.285707 $15694.7300 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 299 305 2452.233302 $132420.6700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 1 1 9.142857 $493.7200 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 304 313 2518.706318 $30224.4900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 4 4 31.285714 $2544.1600 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 54 55 457.415074 $37197.0700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 1 1 6.142857 $499.5400 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 31 33 293.928568 $23902.3100 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 50 51 378.357140 $30768.0700 $81.3200
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Subtotal (Total Children Is Unduplicated) 377 910 6757.408649 $275371.9400 $40.7500
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Total 995 6797.447531 $276985.1300 $40.7500
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Number of Children (Unduplicated) With at Least One Authorization 395