Summary Report for FSPSAs Initiated During the Report Period Center: 54
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 840 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 4 4 3.477778 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 4 4 3.477778 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AACIS -92597 AAC INTIAL EVAL BY LICENSED SLP 2 2 2.000000 $233.6600 $116.8300
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 16 18 10.061111 $487.9600 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 2.111111 $130.2800 $61.7100
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 2 2 1.150000 $17.4700 $15.1900
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 1 1 0.127778 $2.0600 $16.1500
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 10 11 10.322222 $250.6200 $24.2800
AUDE -V5010 ASSESSMENT FOR HEARING AID 9 10 12.069841 $547.0100 $45.3200
AUDE -V5090 DISPENSING FEE PER HEARING AID 1 1 0.677778 $78.5000 $115.8100
SPCH -92521 EVAL OF SPEECH FLUENCY 2 2 4.428571 $257.3500 $58.1100
SPCH -92523TL EVAL OF SPCH SOUND PROD; EVAL LANG 1 1 0.944444 $54.8800 $58.1100
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Subtotal (Total Children Is Unduplicated) 43 53 43.892856 $2059.7800 $46.9300
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 2 2 2.000000 $95.8800 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 12 14 19.700000 $98500.0000 $5000.0000
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 0.133333 $9.2400 $69.3300
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 131 146 125.348416 $6267.4300 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 4 4 5.500000 $275.0000 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 2 2 -3.450000 $-172.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 2 3 -4.666667 $-233.3400 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 2 2 1.444444 $39.0000 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 262 287 1384.357130 $74755.4000 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 38 40 148.827775 $8036.7300 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 37 38 50.895239 $4138.8200 $81.3200
OCCT -97530GO OT SESSION BY LICENSED OT 3 3 10.266667 $834.8900 $81.3200
OCCT -97530GOGT OT SESSION BY LICENSED OT 6 6 7.534921 $612.7400 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 8 9 52.261903 $3403.3000 $65.1200
OCCT -97530HMGT OT SESSION BY OT ASST 1 1 12.857143 $837.2500 $65.1200
OCCT -97530TL OT SESSION BY LICENSED OT 35 38 113.746826 $9249.9100 $81.3200
OCCT -97530TLGO OT SESSION BY LICENSED OT 6 7 9.241270 $751.5000 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 0.071429 $5.8100 $81.2900
OCCT -97530TLGTHM OT SESSION BY OT ASST 1 1 5.000000 $325.6000 $65.1200
OCCT -97530TLHM OT SESSION BY OT ASST 7 9 0.642856 $41.8700 $65.1300
PHY -97110 PT SESSION BY LICENSED PT 22 22 63.870632 $5193.9500 $81.3200
PHY -97110GP PT SESSION BY LICENSED PT 1 2 2.000000 $162.6400 $81.3200
PHY -97110GPGT PT SESSION BY LICENSED PT 1 1 0.466667 $37.9500 $81.3300
PHY -97110TL PT SESSION BY LICENSED PT 36 37 91.949205 $7477.3100 $81.3200
PHY -97110TLGP PT SESSION BY LICENSED PT 1 2 6.857143 $557.6200 $81.3200
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 1 1 0.677778 $311.2600 $459.2300
SENS -V5264 EARMOLD 3 3 11.892064 $215.6000 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 53 56 114.519837 $9312.7500 $81.3200
SPL -92507GT SPL THERAPY SESSION BY LICENSED SLP 4 5 11.935715 $970.6000 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 39 39 39.682537 $3226.9800 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 0.788889 $64.1500 $81.3200
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Subtotal (Total Children Is Unduplicated) 417 783 2286.353152 $235305.3600 $102.9200
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Total 840 2333.723786 $237365.1400 $101.7100
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Number of Children (Unduplicated) With at Least One Authorization 420