Summary Report for FSPSAs Ending During the Report Period Center: 09
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 288 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 15 15 29.238096 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 15 15 29.238096 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 0.466667 $12.1500 $26.0400
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 0.466667 $10.8000 $23.1400
AUDE -92651 AEP HEARING STATUS DETER I&R 1 1 0.466667 $36.5200 $78.2600
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 1 1 6.000000 $300.0000 $50.0000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 3 3 9.714287 $564.4900 $58.1100
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Subtotal (Total Children Is Unduplicated) 5 7 17.114288 $923.9600 $53.9900
EI Services, Class # 03
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 58 87 121.500000 $6075.0000 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 9 9 10.000000 $250.0000 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 42 43 39.911112 $1995.5600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 15 15 14.655555 $732.7800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 12 12 13.261111 $663.0600 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 25 25 25.094445 $1254.7300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 39 40 212.199999 $11458.8000 $54.0000
OCCT -97530 OT SESSION BY LICENSED OT 10 11 60.071428 $4885.0100 $81.3200
OCCT -97530HM OT SESSION BY OT ASST 1 1 8.571429 $558.1700 $65.1200
PHY -97110 PT SESSION BY LICENSED PT 10 11 51.459523 $4184.7000 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 11 12 65.285714 $5309.0200 $81.3200
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Subtotal (Total Children Is Unduplicated) 140 266 622.010316 $37366.8200 $60.0700
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Total 288 668.362700 $38290.7800 $57.2900
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Number of Children (Unduplicated) With at Least One Authorization 155