Summary Report for FSPSAs Ending During the Report Period Center: 54
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 950 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 9 9 8.244445 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 9 9 8.244445 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 1.522222 $177.8400 $116.8300
AACIS -92597TL AAC INTIAL EVAL BY LICENSED SLP 2 2 2.000000 $233.6600 $116.8300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 20 23 17.150001 $831.7800 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 8 9 4.983333 $307.5200 $61.7100
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.383333 $6.1900 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 17 17 13.833332 $335.8700 $24.2800
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 1 1 1.000000 $49.5900 $49.5900
AUDE -V5010 ASSESSMENT FOR HEARING AID 15 16 5.700002 $258.3300 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 2 0.755556 $87.5100 $115.8200
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 1.544444 $89.7500 $58.1100
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Subtotal (Total Children Is Unduplicated) 62 75 48.872223 $2378.0300 $48.6600
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 3 3 2.577778 $123.5800 $47.9400
AACFIT-92609TL AAC FITTING, ADJUST, TRAINING VISIT 1 1 0.333333 $15.9800 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 12 14 22.200000 $111000.0000 $5000.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 123 140 121.053971 $6052.7100 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 5 5 5.611111 $280.5600 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 1 1 0.238889 $11.9500 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 1 1 2.000000 $100.0000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 2 0.611111 $30.5600 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 301 345 1514.312707 $81772.8700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 31 33 173.431746 $9365.3100 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 39 40 83.207936 $6766.4600 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 5 5 19.338096 $1572.5700 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 2 2 1.155556 $93.9700 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 8 9 23.495239 $1530.0100 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 0.285714 $18.6000 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 42 44 110.577776 $8992.1900 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 15 15 44.827779 $3645.3900 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.071429 $5.8100 $81.2900
OCCT -97530TLHM OT SESSION BY OT ASST 11 12 38.929365 $2535.0900 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 28 28 52.879367 $4300.1700 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 5 5 16.817460 $1367.6000 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 5.571429 $453.0700 $81.3200
PHY -97110GT PT SESSION BY LICENSED PT 2 2 3.285714 $267.2000 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 29 31 63.887302 $5195.3100 $81.3200
PHY -97110TLGP PT SESSION BY LICENSED PT 1 1 5.857143 $476.3000 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 7.285714 $592.4700 $81.3200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 2 0.755556 $346.9900 $459.2500
SENS -V5264 EARMOLD 3 5 7.469842 $135.4300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 63 70 142.142859 $11559.0800 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 4 6.912698 $562.1300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 37 40 45.094445 $3667.0700 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 2 2 5.285714 $429.8400 $81.3200
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Subtotal (Total Children Is Unduplicated) 438 866 2527.504779 $263266.2400 $104.1600
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Total 950 2584.621447 $265644.2700 $102.7800
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Number of Children (Unduplicated) With at Least One Authorization 447