Summary Report for FSPSAs Initiated During the Report Period Center: 53
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 619 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 21 22 28.417459 $0.0000 $0.0000
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Subtotal (Total Children Is Unduplicated) 21 22 28.417459 $0.0000 $0.0000
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 11 11 8.883333 $430.8400 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 0.061111 $3.7700 $61.7000
AUDE -92550 TYMPANOMETRY & REFLEX THRESH 1 1 0.061111 $0.9300 $15.1900
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 33 33 18.655556 $452.9600 $24.2800
AUDE -92650 AEP SCR AUDITORY POTENTIAL 1 1 1.000000 $54.9000 $54.9000
EXIT -EXIT COS Exit 3 3 4.000000 $200.0000 $50.0000
SPL -92526 TREATMENT OF SWALLOWING DYSFUNCTION 1 1 3.600000 $209.2000 $58.1100
SPL -92526TL TREATMENT OF SWALLOWING DYSFUNCTION 2 2 11.828571 $687.3600 $58.1100
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Subtotal (Total Children Is Unduplicated) 51 53 48.089682 $2039.9500 $42.4200
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 12 13 10.450000 $52250.0000 $5000.0000
AUDE -V5160 DISPENSING FEE BINAURAL 3 3 1.594444 $369.2900 $231.6100
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 9 12 5.642857 $282.1500 $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 2.983333 $149.1700 $50.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 22 23 31.984920 $1599.2400 $50.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 25 26 36.431744 $1821.5800 $50.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 38 41 100.954761 $5047.7400 $50.0000
CONSF -CONSFGT CONSULT, SLP, TELEMEDICINE 1 1 4.200000 $210.0000 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 4 4 4.183333 $104.5800 $25.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 192 200 1089.204774 $58816.9900 $54.0000
EIIF -T1027SCGT EI INDIVIDUAL SESSION BY EI PROF 17 17 80.671429 $4356.2600 $54.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 48 58 362.799208 $4353.5900 $12.0000
OCCT -97530 OT SESSION BY LICENSED OT 19 20 113.876193 $9260.4000 $81.3200
OCCT -97530TL OT SESSION BY LICENSED OT 30 30 207.552385 $16878.1500 $81.3200
OCCT -97530TLGT OT SESSION BY LICENSED OT 1 1 4.714286 $383.3700 $81.3200
PHY -97110 PT SESSION BY LICENSED PT 13 13 58.657144 $4769.9900 $81.3200
PHY -97110TL PT SESSION BY LICENSED PT 15 15 74.253969 $6038.3300 $81.3200
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 23 24 113.585716 $9236.7900 $81.3200
SPL -92507TL SPL THERAPY SESSION BY LICENSED SLP 34 34 154.901591 $12596.5800 $81.3200
SPL -92507TLGT SPL THERAPY SESSION BY LICENSED SLP 1 1 7.428571 $604.0900 $81.3200
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Subtotal (Total Children Is Unduplicated) 357 544 2469.356372 $189292.5500 $76.6600
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Total 619 2545.863513 $191332.5100 $75.1500
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Number of Children (Unduplicated) With at Least One Authorization 378