Summary Report for FSPSAs Ending During the Report Period Center: 53
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 480 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 12 14 14.516666 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 12 14 14.516666 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 6 7 6.161111 $298.8100 $48.5000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 1.000000 $15.1900 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 20 20 9.794446 $237.8100 $24.2800
EXIT -EXIT COS Exit 2 2 3.000000 $150.0000 $50.0000
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 1 1 0.366667 $21.3100 $58.1200
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Subtotal (Total Children Is Unduplicated) 29 31 20.322224 $723.1300 $35.5800
EI Services, Class # 03
AACFIT-92609 AAC FITTING, ADJUST, TRAINING VISIT 1 1 1.355556 $64.9900 $47.9400
ASST -ASST ASSISTIVE TECHNOLOGY 4 5 3.605555 $18027.5000 $4999.9200
AUDE -V5160 DISPENSING FEE BINAURAL 2 2 2.000000 $463.2400 $231.6200
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 11 14 7.642857 $382.1500 $50.0000
COIFF -COIFFGT IFSP CONSULT, PROF, TELEMEDICINE 5 5 3.285714 $164.2900 $50.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 3 3 3.607143 $180.3600 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 16 16 19.001588 $950.0800 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 14 16 1.950000 $97.5000 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 28 28 25.276188 $1263.8000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 1 1 0.933333 $23.3300 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 142 146 606.019042 $32725.0700 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 13 13 43.876189 $2369.3100 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 57 64 281.601585 $3379.2300 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 20 21 127.280949 $10350.5100 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 23 23 100.685716 $8187.7800 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 4.857143 $394.9800 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 10 10 62.638094 $5093.7500 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 12 14 66.601587 $5416.0300 $81.3200
PHY -97110TLGT PT SESSION BY LICENSED PT 1 1 4.333333 $352.3800 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 18 19 78.309523 $6368.1300 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 31 32 125.434919 $10200.3800 $81.3200
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Subtotal (Total Children Is Unduplicated) 275 435 1570.296014 $106454.7800 $67.7900
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Total 480 1605.134904 $107177.9000 $66.7700
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Number of Children (Unduplicated) With at Least One Authorization 286