Summary Report for FSPSAs Initiated During the Report Period Center: 04
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: 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 1833 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 57 61 33.650791 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 57 61 33.650791 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 4 4 4.000000 $246.8400 $61.7100
OCTH -97167TL OT EVAL HIGH COMPLEXITY 45 47 15.615874 $907.4400 $58.1100
PSTH -97161TL PT EVAL LOW COMPLEXITY 2 2 0.727778 $42.2900 $58.1100
PSTH -97163TL PT EVAL HIGH COMPLEXITY 33 34 7.344445 $426.7900 $58.1100
SENS -V5014TS HEARING AID REPAIR IN-OFFICE 1 1 1.000000 $15.1100 $15.1100
SPCH -92521TL EVAL OF SPEECH FLUENCY 33 34 8.866668 $515.2500 $58.1100
SPCH -92610TL EVAL OF ORAL,PHARYNGEAL SWALLOWING 1 1 0.061111 $3.5500 $58.1000
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.142857 $8.3000 $58.1300
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Subtotal (Total Children Is Unduplicated) 73 124 37.758733 $2165.5700 $57.3500
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 49 8.433334 $421.6700 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 5 5 2.844444 $142.2200 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 7 7 5.036507 $251.8200 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 4 5 2.311111 $115.5600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 4 4 3.136508 $156.8300 $50.0000
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 87 102 534.857149 $14441.1400 $27.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 583 636 3992.101604 $215573.4800 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 4 4 30.428572 $1643.1400 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 582 632 4033.659538 $48403.9100 $12.0000
OCCT -97530TL OT SESSION BY LICENSED OT 77 82 375.357152 $30524.0000 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 12.428571 $1010.6900 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 50 54 242.000005 $19679.4200 $81.3200
SENS -V5264 EARMOLD 1 1 1.000000 $18.1300 $18.1300
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1 1 5.428571 $441.4500 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 60 63 265.461908 $21587.3300 $81.3200
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Subtotal (Total Children Is Unduplicated) 684 1648 9516.484974 $354874.0200 $37.2900
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Total 1833 9587.894498 $357039.5900 $37.2400
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Number of Children (Unduplicated) With at Least One Authorization 725