Summary Report for FSPSAs Ending During the Report Period Center: 53
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 460 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 11 11 18.661111 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 11 11 18.661111 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 6 4.633333 $224.7200 $48.5000
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 23 23 14.444445 $350.7100 $24.2800
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 2.133333 $123.9700 $58.1100
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Subtotal (Total Children Is Unduplicated) 28 30 21.211111 $699.3900 $32.9700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 6 6 6.633333 $33166.5000 $4999.9800
AUDE -V5160 DISPENSING FEE BINAURAL 4 4 4.000000 $926.4800 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 12 8.714286 $435.7200 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 3 3 1.750000 $87.5000 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.288889 $14.4500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 3 3 5.300000 $265.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 5 5 5.955555 $297.7800 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.022222 $0.5600 $24.9800
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 218 227 1125.941264 $60800.8400 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 8 8 41.485715 $2240.2200 $54.0000
INTR -T1013 INTERPRETER 1 1 2.000000 $100.0000 $50.0000
OCCT -97530 OT SESSION BY LICENSED OT 15 15 63.128570 $5133.6300 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 8 8 17.721429 $1441.1000 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 1 1 0.285714 $23.2300 $81.3200
OCCT -97530GT OT SESSION BY LICENSED OT 1 1 11.285714 $917.7500 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 4 5 17.140477 $1393.8700 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 31 31 107.098413 $8709.2500 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 7 7 19.871428 $1615.9400 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 7 7 29.796826 $2423.0800 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 3.866667 $314.4400 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 1 1 8.142857 $662.1800 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 18 19 68.828571 $5597.1300 $81.3200
SENS -V5264 EARMOLD 1 1 0.644444 $11.6800 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 17 17 91.914288 $7474.4700 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 5 5 21.933334 $1783.6200 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 28 28 128.226985 $10427.4100 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 1.833333 $149.0800 $81.3200
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Subtotal (Total Children Is Unduplicated) 324 419 1793.810314 $146412.9300 $81.6200
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Total 460 1833.682536 $147112.3200 $80.2300
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Number of Children (Unduplicated) With at Least One Authorization 331