Summary Report for FSPSAs Ending During the Report Period Center: 04
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: 01-01-24 and 03-31-24 Date of Report: 04-04-25 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 1767 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 35 39 16.066666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 35 39 16.066666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 5 5 5.000000 $308.5500 $61.7100
OCTH -97165TL OT EVAL LOW COMPLEXITY 1 1 0.250000 $14.5300 $58.1100
OCTH -97167 OT EVAL HIGH COMPLEXITY 1 1 0.350000 $20.3400 $58.1100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 47 50 18.434125 $1071.2000 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 1 1 0.200000 $11.6200 $58.1100
PSTH -97162TL PT EVAL MODERATE COMPLEXITY 1 1 0.133333 $7.7500 $58.1000
PSTH -97163TL PT EVAL HIGH COMPLEXITY 28 30 7.772222 $451.6400 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.1100 $15.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 39 40 7.499999 $435.8200 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.142857 $8.3000 $58.1300
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Subtotal (Total Children Is Unduplicated) 80 131 40.782536 $2344.8600 $57.5000
EI Services, Class # 03
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 25 60 15.730556 $786.5300 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 7 7 1.966667 $98.3400 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 10 10 8.906350 $445.3200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 2 2 0.144444 $7.2200 $49.9800
CONSF -CONSF CONSULT, SLP, FACE TO FACE 7 7 5.749207 $287.4600 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 94 110 592.285703 $15991.7400 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 538 594 4023.392065 $217263.2100 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 6 6 23.428570 $1265.1400 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 534 593 4092.811113 $49113.7400 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 1 1 3.714286 $302.0500 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 71 85 432.785708 $35194.1800 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 46 52 205.714286 $16728.7100 $81.3200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 3.285714 $267.1900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 55 66 223.247615 $18154.5400 $81.3200
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Subtotal (Total Children Is Unduplicated) 653 1597 9636.162284 $356386.7400 $36.9800
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Total 1767 9693.011486 $358731.6000 $37.0100
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Number of Children (Unduplicated) With at Least One Authorization 681