Summary Report for FSPSAs Initiated During the Report Period Center: 06
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 1312 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 38 38 31.841268 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 38 38 31.841268 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 2 3.333333 $205.7000 $61.7100
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 3 3.000000 $347.4300 $115.8100
EXIT -EXIT COS Exit 121 122 122.000000 $6100.0000 $50.0000
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Subtotal (Total Children Is Unduplicated) 123 127 128.333333 $6653.1300 $51.8400
EI Services, Class # 03
AUD -92630 AUD REHAB PRELING HEARING LOSS 16 16 17.079367 $1184.4700 $69.3500
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 84 87 71.029482 $3551.4700 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 55 56 57.502753 $2875.1300 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 8 8 4.511111 $112.7800 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 7 10.116667 $505.8400 $50.0000
CONIF -CONIFGT CONSULT, ITDS, TELEMEDICINE 2 2 2.450000 $122.5000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 2.516666 $125.8300 $50.0000
CONOF -CONOFGT CONSULT, OT, TELEMEDICINE 1 1 2.200000 $110.0000 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 3 3 5.400001 $270.0100 $50.0000
CONPF -CONPFGT CONSULT, PT, TELEMEDICINE 1 1 1.450000 $72.5000 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 323 390 2365.169805 $127719.1900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 32 38 238.152377 $12860.2400 $54.0000
INTR -T1013 INTERPRETER 59 99 307.250000 $15362.5000 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 325 401 2432.850756 $29194.2100 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 2 2 18.000000 $1463.7600 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 4 4 16.428571 $1335.9700 $81.3200
PHY -97110HM PT SESSION BY PT ASST 2 2 16.857142 $1097.7400 $65.1200
PHY -97110HMGT PT SESSION BY PT ASST 1 1 5.428571 $353.5100 $65.1200
SENS -V5060 BEHIND EAR HEARING AID 4 5 5.000000 $1148.0500 $229.6100
SENS -V5264 EARMOLD 10 11 13.776192 $249.7700 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 5 7 47.285714 $3845.2700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 3 3 29.714285 $2416.3800 $81.3200
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Subtotal (Total Children Is Unduplicated) 396 1147 5670.169460 $205977.0900 $36.3300
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Total 1312 5830.344061 $212630.2200 $36.4700
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Number of Children (Unduplicated) With at Least One Authorization 527